* = Required Information

Questions Yes No Comments
1. Were you satisfied with the agency's efforts to support your quality of life?
2. Was the care delivered in a timely manner?
3. Did you feel the staff was available on weekends and after hours when you needed them?
4. Did you understand your treatment plan and other services provided?
5. Do you know how to file a complaint with the state and/or agency?
6. Were you notified if there was a change in your condition and/or change in discipline in a timely manner?
7. Were your safety needs identified and were appropriate measures taken to improve your safety at home?
8. Overall, do you feel the organization has met your needs and expectations?
Thank you for taking the time to complete this survey.
Additional Comments:

Signature (optional)

Date

Security Code *