County:	District:
Program Name:	Type:
Review Period:
Staff Completing Report:
Title:	Date:

Have you referred to this program within the past six months? Yes No

If no, state why and stop here.

(If answering “no” to any of these questions, please briefly

explain and provide feedback for improvement.)

1) Are the services offered by the program satisfactory?	Yes No

2) Are consumers reasonably satisfied with the program’s services? Yes No

3) Are services easily accessible? Yes No

4) Is there regular communication between the program and the local court counselors’ office?

Yes	No

5) Are monthly progress reports or client progress updates provided by the program for

court referred juveniles? Yes No

6) Is the length of time between referral and admission reasonable for this program

type? Yes No

List any pertinent program strengths/weaknesses.