A Friend of the Family ::: Client Survey

Name:
Email address:
Name of Caregiver:
Date of Care:
Arrived on time?:	Yes No
Please rate the following from 1 to 5 with 5 being the highest rating
Interactive:
Knowledgeable about caring for my child(ren):
Professional:
Personable:
Communication skills:
Appearance:
Followed instructions:
Good match for our family:
Warm and loving:
I would request her again as:	(You may have as many 1st preferences as you like.)
Your comments:
I do not wish to have this caregiver again for the following reasons:
Your response is extremely important to us to ensure A Friend of the Family maintains the quality of care we expect of our caregivers. We would like the opportunity to share both positive and negative information with your caregiver. We will do so only with your permission.
Select one: I give my permission to share this survey with the caregiver. I do not wish this survey to be shared with the caregiver.
Thank you for taking the time to provide us with your evaluation. If you refer a friend who at the time of registration gives us your name, you will receive a $50 credit to your Friend of the Family account.

Atlanta, GA • Athens, GA • Greenville, SC • Charlotte, NC

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