Behaviour Support Survey Phase Change 2-3

Name of Child

Name of those who filled out this survey/were present when survey was filled out

Relationship to Child

If possible, did the child assist with filling out this survey?

Yes

No

1. Have you noticed a positive behaviour change in the child?

Yes

No

Comments

2. Do you feel that this plan continues to be respectful of the child and their needs?

Yes

No

Comments

3. Do you feel that this plan is helping support the child?

Yes

No

Comments

4. Does the plan continue to reflect the cultural and family values while considering the family’s current situation?

Yes

No

Comments

5. Do you feel that there has been an appropriate level of communication for this plan to be effective and clear to you?

Yes

No

Comments

6. Do you feel that an appropriate level of coaching has been provided to help you understand the plan and learn new ways to support the child?

Yes

No

Comments

7. Do you feel that you can continue to run this plan even when the consultant isn’t present, but with continued support from the consultant?

Yes

No

Comments