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2. Youth First Name
3. Youth Last Name
5. Parent/Guardian First Name
6. Parent/Guardian Last Name
8. Mobile Phone
9. Email
10. Case Number
12. Were you referred to a local mental health professional?

    1. Yes

    1. No
14. Did you meet with mental health professional?

    1. Yes

    1. No
16. How can we better assist you in meeting with a mental health professional to best serve your family?
18. Has your child set a fire since they attended the GJFD Youth Fire Intervention?

    1. Yes

    1. No
20. Has your family practiced your home fire escape plane?

    1. Yes

    1. No
22. Are all lighters and matches still out of reach of children?

    1. Yes

    1. No
24. Has your family discussed your child's fire setting since attending the GJFD Youth Fire Intervention?

    1. Yes

    1. No
26. Has your child gotten in any major trouble at school or at home since the program?

    1. Yes

    1. No
28. How would you rate your child's behavior since the youth fire intervention?
30. Emotionally:

    1. Worse

    1. Same

    1. Improved
32. Use of Fire:

    1. Worse

    1. Same

    1. Improved
34. Behavior in school:

    1. Worse

    1. Same

    1. Improved
36. As a parent or guardian, how satisfied were you with:
38. Fire education provided by GJFD

    1. Not at all satisfied

    1. Somewhat satisfied

    1. Very satisfied
40. GJFD employee skills/rapport with your child

    1. Not at all satisfied

    1. Somewhat satisfied

    1. Very satisfied
42. Information provided to you as a parent/guardian

    1. Not at all satisfied

    1. Somewhat satisfied

    1. Very satisfied
44. Ease of intervention process

    1. Not at all satisfied

    1. Somewhat satisfied

    1. Very satisfied
46. Resources and/or referrals given

    1. Not at all satisfied

    1. Somewhat satisfied

    1. Very satisfied

    1. N/A
48. Anything else you'd like to share with us about your experience, your child's progress, or how to improve our program?
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50. 1. Receive an email copy of this form.
51. Email address

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52. Submit

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