Arizona Department of Health
Office for Children with Special Health Care Needs
Child / Family/ Teen Satisfaction Survey
for TBI Service Coordination
Thank you for taking the time to complete this survey. Your responses are very important to us.
All information gathered will be kept confidential and we welcome additional comments, suggestions or concerns.
Please complete this survey about the TBI Service Coordination and mail it in the envelope provided.
The TBI Service Coordination process, includes the steps taken to help you find and receive supports and services for
your child / teen and family. The TBI Service Coordinator is the person who assists you with the process and helps you
develop and monitor the Individualized Service Plan for Child / Teen with a Traumatic Brain Injury.
If you have any questions or would like assistance in filling out the survey, ask your Service Coordinator. He/she will be
glad to assist you or recommend someone else who can assist you. You may also ask a friend or relative to help.
Please circle the number which best reflects your opinion of each of the following statements about your
Service Coordinator.
1 = Strongly Agree 2 = Agree 3 = Disagree 4 = Strongly Disagree
Our Service Coordinator:
1. Was easy to contact and returned our phone calls in a timely manner. 1 2 3 4
2. Met us at times and places that supported our needs. 1 2 3 4
3. Made us feel comfortable, listened to our questions, and helped us find 1 2 3 4
answers.
4. Helped us understand the steps needed to advocate for our child / teen and 1 2 3 4
family to get the supports and services.
5. Included our priorities, resources and concerns when planning supports and 1 2 3 4
services in the development of the Individualized Service Plan for Child /
Teen with a Traumatic Brain Injury.
6. Helped us identify how we could support our child in the things he/she does 1 2 3 4
everyday.
7. At my request, willingly informed key people in the child / teen’s life 1 2 3 4
(family, friends, teachers, school, schoolmates etc) about Traumatic
Brain Injury and its effects.
8. Showed genuine concern for the needs of our child / teen and family. 1 2 3 4
9. Assisted us as needed or requested in completing applications for services 1 2 3 4
(Az Long Term Care Services, Social Security Income, Assistance for
Families, Children’s Rehabilitative Services,) or school accommodations
and IEP, 504 ).
10. Respected our family’s culture and lifestyle. 1 2 3 4
11. Is knowledgeable about TBI, resources, services and how to obtain them. 1 2 3 4
12. Assisted our child / teen and family to meet the goals stated in the 1 2 3 4
service plan.
See other side
This survey will be used by the Arizona Department of Health Services, Office for Children with Special Health Care Needs
(OCSHCN) to improve services for child/teen with TBI and their family.
Child / Family/ Teen Satisfaction Survey for TBI Service Coordination continued
Additional Information :
Did working with the Service Coordinator benefit your child/teen and family?
__ Yes __ No
What was most helpful
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Least helpful
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Suggestions for improvement
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Our family feels the best time for families to be informed about the availability of TBI Service Coordination is:
(Mark all that apply)
___ within 1 week of injury ___ within 6 month of injury
___ within 1 month of injury ___ after 1 year
___ before child enters or returns to school
Over all, our satisfaction with the TBI Service Coordination process is:
____ Very Satisfied _____ Satisfied _____Dissatisfied ____Very Dissatisfied
Explanation of choice (if desired)
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Additional comments, suggestions, concerns / praise
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Demographic Information
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Service Coordinator name / provider Today’s date
________________________ __________________________________ ______________
County School district Zip code
This survey will be used by the Arizona Department of Health Services, Office for Children with Special Health Care Needs
(OCSHCN) to improve services for child/teen with TBI and their family.