Satisfaction Survey of MARE Services
In order to better understand the needs of families interested in foster care and/or adoption, and to continue to provide the best possible service to these families, we ask that you take a moment to answer the following questions. All information is voluntary; please do not answer any question you feel is inappropriate. The information you provide will only be used to maintain or enhance the quality of the MARE program and its services to families. Your identity will be kept completely confidential.
Name: Mailing Address:
City:
State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NY NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip Code:
Phone Number: format (xxx-xxx-xxxx)
Email Address:
Race:
Marital Status:
Age:
Gender: Male Female
How did you originally learn about MARE? Agency Internet Advertisement Word of Mouth Yellow Page / Phone Book Other:
What date did you have initial contact with MARE? format (MM/DD/YYYY)
How did you contact MARE? Phone Email/Website Other:
With which MARE staff person did you have contact? Michelle Jennifer Heidi Christopher Loren Carla Jamee Sheila Brandon Uncertain
What was your purpose for contacting MARE?
Were your questions or concerns addressed promptly and courteously? Yes No
If No, please explain:
Did you receive adequate information to answer you questions or address your concerns? Yes No If No, please explain:
Was there other information that would have been helpful? Yes No
If yes, what else do you think would have been helpful?
Would you like MARE to follow up with you regarding your questions or concerns? If so, what is the best method and time to reach you?
Where are you in the adoption or foster care process? Approved Adoptive Family (Family Assessment complete) Licensed foster family (Foster care license complete) In process (Working with agency/Family Assessment or foster care license not complete) Not yet working with an agency
Please tell us abut the child(ren) you hope to foster and/or adopt (check all that apply): Younger than 6 years old 6-10 years 11-13 years 14 or older Infant only International only African American Caucasian Hispanic Other No Preference Siblings Single Child only
Will Consider: Emotional/Behavioral Issues: Yes No
Physical Impairments: Yes No
Developmental Delays: Yes No
Learning Impairments: Yes No
Other:
Are you now or have you been: Adoptive Parent Foster Parent
