Woodbury Reports Confidential
Residential School/Program Survey
We would very much appreciate you taking the few minutes to fill out this form. Feedback of this type from parents and ex-students are vital to our attempts to measure effectiveness of various types of residential facilities.

Please complete one separate survey for each person reporting and for each facility attended. We must have your name and phone number so we can verify this survey is from you, and so we can ask questions if an answer is unclear. Although brief answers are preferred, feel free to use as much space as you feel is necessary.

(The contents of this response remain the property of Woodbury Reports Inc. Judi Besette will be helping us in the analysis of the responses. Strict confidentiality will be maintained and neither your name nor your response will be released to any other party except by your express written permission. We do reserve the right to publish aggregate totals in the Woodbury Reports newsletters from time to time, but only in a manner that will not violate individual confidentiality.)

Your Name
Address
City, State, Zip
Phone
e-Signature	I give my permission for my responses to be used in aggregate totals to be published from time to time in the Woodbury Reports Inc. newsletters. (Surveys without an electronic signature cannot be used and will be discarded). By checking this box I agree to these terms and wish to continue with the rest of the survey.
Email
Your Age
Your Sex	Male     Female
Today's Date
Student's Age	(at time of attendance)
Student's Sex	Male     Female
Your relationship with the school/program at the time of attendance
	Student/Patient  Mother  Father   Step-Mother  Step-Father  Other
Name, city & state of school/program attended (address & phone if known)
Dates of Attendance	(Arrival date)  — (Ending date)
Completed Program	Yes    Left Early    Still Attending
Please write a brief phrase that describes the school/program.
What were the behaviors/issues/diagnoses that led to the placement?
How did you hear about the program?
What made you choose this school/program?
Please list up to five or six adjectives that best describe this school/program.
Please list up to five or six adjectives that best describe your experience with this school/program.
What in your view were the most effective or beneficial elements and/or persons of the school/program (if any)?
What in your view were the weakest or most troublesome elements and/or persons of the school/program (if any)?
What behaviors/issues/diagnoses were identified and worked with in the school/program (if any)?
What changes in the student/patient had occured upon leaving the school/program (if any)?
If it has been some time since graduation, what long-term changes do you attribute to this school/program (if any)?
How would you rate this program on a scale of 0 to 5?
	0 - having a negative effect  1 - having no effect
	2 - a little helpful  3 - helpful
	4 - very helpful  5 - very effective and appropriate
May Woodbury Reports Inc. contact you for an interview or to ask for your permission to participate in further research?
	YES  NO
Any additional comments you'd like to include are welcome.

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