YMCA Childcare Resource Services

LOOKING FOR CHILD CARE?

Special Needs Unit (SNU) >Respite Provider Evaluation

Date:
Respite Provider Name:
Client Name (optional):
Primary Guardian (optional):
(If you would like special needs unit staff to contact you please make sure you list your name or client name)

1. History: About how long has your respite provider been provider been providing child care for your child(ren)?
Less than 3 months	3 to 6 months	6 months to 1 year
More than 3 years	Our provider is a member of the immediate family
2. Reliability: Does your provider keep appointments and return phone calls in a timely manner?
Always Most of the time Sometimes Rarely
Comments:

3. Skill: How satisfied are you with your provider's ability to respond appropriately to challenging behaviors or situations?
Very Satisfied Satisfied Dissatisfied Very dissatisfied
Comments:

4. To be contacted by a special needs unit staff person please check box (name must be provided on top of form)
5. Qualify: How do you feel about your provider's interactions with your child? How satisfied are you with his/her enthusiasm and the frequency that he/she engages in activities?
Very Satisfied Satisfied Dissatisfied Very Dissatisfied
Comments:

6. Professionalism: Does your provider handle himself/herself in a professional manner when interacting with you?
Always Most of the time Sometimes Rarely
7. Development: What types of trainings do you think might benefit YMCA respite providers or yourself?

8. E-mail Address: Please include your e-mail address to receive future evaluations by e-mail

9. General comments relating to your provider:

The YMCA strives to maintain a connection with our respite providers by making (1/2 to 1 hour) home visits. Meeting with providers while they are working also allows an opportunity to observe their interactions with your children. To assist in this process, please include whether you have a routine schedule or any future dates and times scheduled for respite care. (You will be contacted for confirmation before a home visit is made. If you have any questions regarding home visits please contact Veronica Orona at 619-474-4707 ext. 1413)