Family-Teen Mediation Survey – Caregiver

Your feedback on the services at Intersect is important.

We use this information to make sure we are meeting your needs in a meaningful way, to identify areas we can improve on and to plan for the future.

What to know about this survey:

  • You don’t have to do it if you don’t want to.
  • Your responses are anonymous and confidential; you do not have to record your name.
  • Your answers will not affect your ability to access services at Intersect.

Please fill out as much information as possible.

MM slash DD slash YYYY

Youth's Information

Person completing the Survey Information

The total number of mediation visits our family has had with the mediator are (best guess)

Please select which of the following services you and your youth have accessed at Intersect

Individual therapy / counselling
Referrals to other services
Family-Teen Mediation
Parenting Through Strong Emotions

Please indicate how much you agree with the following statements:

I understand what confidentiality is, and its limitations.
My family’s culture and religious beliefs are respected.
Our gender and sexual orientation are respected.
We have made a list of topics/issues since starting mediation.
My youth has more healthy and effective coping skills since using mediation services.
My family has been able to talk about emotions more effectively since participating in mediation services.
My relationship with my youth has improved.
I have a greater understanding of what my youth is going through.
I know about other resources in the community that can help my youth and my family.
I feel supported by my mediator in community meetings (i.e. school, hospital, etc.).
I have been included by the mediator during our agreement making.
I am aware of how long mediation services can work with my family.
I know what to do if I have a concern or complaint about the services my family receives through mediation.
I feel safe during mediation visits.
I feel respected while with my mediator.
I feel comfortable while with my mediator.
I feel more hopeful since using mediation services.
I would refer my friends/family to Family-Teen mediation.

Please rate your level of satisfaction with the following:

The hours of services.
The appearance and cleanliness of the building.
The physical accessibility of the building (e.g., ramps, stairs, etc.).
The time of day when services were scheduled.
The mediator respects our confidentiality.
The courtesy and respectfulness of staff.
Information found on the Intersect Website.
Overall, how satisfied are you with the quality of services you have received so far?

FAMILY TEEN MEDIATION PROGRAM PARTICIPANT EVALUATION SUMMARY – Please indicate how much you agree with the following statements:

My mediator was flexible when they could meet for home visits.
During mediation, I felt my perspective was understood by my mediator.
During mediation, I felt my perspective was understood by the family member.
During mediation, I began to understand the family member’s perspective.
The mediation helped me address topics/issues identified.
During mediation, we developed written agreements.
I feel better after mediation.
The mediator was able to provide variety of community resources I could use.
This field is for validation purposes and should be left unchanged.