Home
About
Our Vision & Values
Our Mission
Meet our Team
Message from the Administrator
Need Our Services?
Invoice
Services
Long Term Care Services
Services for under 21 y/o
Medicaid Waiver Services
Insurance Accepted
Resources
Community Inclusion
Continue Education
Covid 19
Health Summary
Home
About
Our Vision & Values
Our Mission
Meet our Team
Message from the Administrator
Need Our Services?
Invoice
Services
Long Term Care Services
Services for under 21 y/o
Medicaid Waiver Services
Insurance Accepted
Resources
Community Inclusion
Continue Education
Covid 19
Health Summary
Consumers
Consumer Resources
Need our Services?
Community Inclusion
Evaluation form
Name of the Direct Service Provider ( Caregiver)
*
First Name
Last Name
Client Name
*
First Name
Last Name
Name of the Person completing evaluation
*
First Name
Last Name
Email of person completing evaluation
*
Is the Caregiver reliable?
*
Yes
No
Does the Caregiver respects His/Her choices and rights?
*
Yes
No
Does the caregiver constantly encourage him/her to do activities he/she enjoy?
*
Yes
No
Is the caregiver actively working on his/her goals and communicating the progress or lack/thereof with you?
*
Yes
No
What areas would you like the caregiver to improve?
*
From 1/10 with 10 being the highest, how would you rate the caregiver services?
*
1
2
3
4
5
6
7
8
9
10
Do you want to continue using the caregiver services?
*
Yes
No
Any additional comments?
Thank you!
