Provider Questionnaire

1. Agency Name/Site:
   Address:
   City: State: Zip:
   Phone Number:
   
2. Services Provided:
   

   Type of Service	# of Persons Served	# of Persons w/ Significant Behavioral Challenges
   CILA - 24-Hour
   CILA Intermittent
   ICF-DD
   Day Program/Dev Training
   Supported Employment

3. Do you serve?

   Adults

   Children

   Both

4. Do you have access to a Behavior Analyst?

   Yes

   No

   Is he/she employed by your agency?

   Yes

   No

5. Do you have a Behavior Analyst on contract?

   Yes

   No

   How many hours does he/she work per week?
6. Do you have a regular meeting of a human rights committee?

   Yes

   No

   What is the frequency of the meetings?
7. Do you have a behavior management committee?

   Yes

   No

8. At the present time, the most difficult category/type of behavior problems for the people we serve and our staff is:
   
9. If your organization has a high degree of success in serving people with challenging behavior, would you be willing to share your experience with others?

   Yes

   No

   via individual consultation

   via counselors and therapists

   via program consultation

   other

   If "other", please explain:
10. Does your agency have access to/utilize video conferencing?

    Yes

    No

11. Staff of our agency would be interested in attending seminars regarding:

    training in applied behavior analysis for QDDPs

    managing aggressive behavior

    structuring day programs for people who are dually diagnosed

    understanding behavior plans

    engaging direct support staff

    basic counseling skills for QDDPs and direct care staff

    other - please identify below

          
12. At the present time, our agency would appreciate receiving informative materials related to:
13. Contact Information:
    Name:
    Office Phone:
    Cell Phone:
    Address: