LITTLE TREASURES DAY CARE
Questionnaire/Referral
Please answer the following questions based on a scale
of 1 to 10 with 1 being poor and 10 being excellent.
Does your child enjoy attending Little Treasures Day Care ?
1 2 3 4 5 6 7 8 9 10
Cleanliness of facility and children?
1 2 3 4 5 6 7 8 9 10
Quality of play equipment?
1 2 3 4 5 6 7 8 9 10
Variety of age-appropriate toys?
1 2 3 4 5 6 7 8 9 10
Reliability of child care?
1 2 3 4 5 6 7 8 9 10
Overall, how satisfied are you with the care your child receives?
1 2 3 4 5 6 7 8 9 10
Nutritional value of meals Corine serves?
1 2 3 4 5 6 7 8 9 10
Fairness of contract and policies?
1 2 3 4 5 6 7 8 9 10
What do you like best about Little Treasures Day Care?
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What do you like least about Little Treasures Day Care??
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Does Little Treasures Day Care offer educational opportunities? Please explain answer.
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Would you recommend Little Treasures Day Care to others? Why or why not?
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Do you feel comfortable and safe leaving your child with Corine?
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How long has Corine cared for your child?
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Any additional suggestions, concerns, and/or comments?
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Can Corine use this form as a referral by you? Yes ____ No ____
Parent Signature __________________________
Phone # (optional) ________________________
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