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RESTRAINT CUSTOMER SATISFACTION SURVEY              Rev 03/10/04

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Must be completed within 48 hours of the restraint.

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Restraining Staff's name: !staff_name_text!
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Kid's Name: !kid_name_text!

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Restraint took place:   !datetext!  !time_text! 

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When typing for log entry,
delete all _unchecked_ entries leaving
only the entry that is checked.
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Check One:
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___ I felt I needed to be restrained so I did whatever
    it took to appear dangerous enough to get restrained.
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___ I was going to hurt either myself or somebody else
    no matter what.
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___ I don't think I needed to be restrained.
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___ Other
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Please explain your checked answer.
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!explain_text!


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Did you choose this staff to restrain you? 
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!yes_or_no_text!
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If so, why? 
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!why_text!


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Check one: I think the staff,
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___ waited too long to restrain me
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___restrained me too soon
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___restrained me at the right time
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If "too long" or "too soon", please explain:
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!explain_too_text!




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Check one: I think the staff,
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___ let up go too soon
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___ let me go at the right time
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___ held me too long
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If "let up too soon" or "held too long", please explain:
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!explain_too__text!



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Do you think this restraint helped you?

!yes_no_or_comment_text!

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What comments or opinions do you have about the restraint
   and about how you and the staff used it to help or hinder
   your treatment progress at the Ranch?
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!comments_text!
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Signed,
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!kids_name!

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