(Optional)

Consumer’s name (Name of the child) _______________________________ Date:__________

TELL ME HOW YOU FEEL

Please help us by answering these simple questions. You do not have to do this survey if
you do not want to. Read the question and circle the face that shows how you feel. There
are no wrong answers.

If you do not know what to

Circle if your answer is Circle if your answer is
YES. answer circle . no.

I don’t
Yes No
know

1. the team members were helpful. N/A

2. My team members were nice. N/A

3. My team members wanted to help me. N/A

4. I saw a team member when I needed to. N/A

5. My team knew how to help me. N/A

6. Our time together was fun. N/A

7. I am happier now. N/A

8. My family is happier now. N/A

I Would you like to say ________________________________________________________

___________________________________________________________________________
___________________________________________________________________________

You Did Great!!!!......................Thank You!!!

QI102.7—Transition Youth Satisfaction Survey Est. Mar 2008