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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?
  4. Do you have access to a Behavior Analyst? Is he/she employed by your agency?
  5. Do you have a Behavior Analyst on contract? How many hours does he/she work per week?
  6. Do you have a regular meeting of a human rights committee? What is the frequency of the meetings?
  7. Do you have a behavior management committee?
  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?


    If "other", please explain:
  10. Does your agency have access to/utilize video conferencing?
  11. Staff of our agency would be interested in attending seminars regarding:





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