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They Have Only Imagined
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181 Union Street
Lynn, MA  01902
Phone: 781-581-9270
http://www.projectcope.com/

Specialized Home Care Program
Respite Care Provider Evaluation

A performance evaluation must be completed by those people who receive respite care and specialized instruction services. The evaluation must be completed by either the individual who receives the direct service, or by his/her parent, foster parent, or legal guardian.

Please respond to the following questions giving careful thought to your response. This is important in order to monitor the quality of services you receive from your care provider.

Person Completing Form:
Care Provider Name:
Individual Receiving Services:
1. How long have services been provided by the above named care provider?
2. Does the Care Provider arrive on time?
3. Does the Care Provider ever cancel an appointment?
4. Can you contact your Care Provider easily?
5. Does your Care Provider consistently follow all instructions that you give him/her?

6. Does your Care Provider accept constructive feed back and suggestions?

7. Do you find your Care Provide cooperative?

8. Is the individual receiving direct services  comfortable while the Care Provider is in the home?

9. Is the family comfortable while the Care Provider is in the home?

10. Does the Care Provider usualy seem to have a good energy level when arriving for appointments?

11. Do you recommend that the Care Provider continue to provide service to you?

12. Do you have a need for another Care Provider in addition to the one you have?