Adult Services Community Friends Survey

Adult Services Community Friends Survey

• Date
  Date:
  MM slash DD slash YYYY
• Name*
  Name:
• Relationship with New Hope*
  What is your relationship with New Hope Services, Inc.?
  • Family/Guardian/Caretaker
  • Case Manager
  • School Partner
  • Medical Professional
  • Vocational Rehabilitation
  • Behavior Clinician
  • State Employee
  • Would Rather Not Say
  • Other Provider
  • Community Partner
  • Employment Partner
  • Other (Can elaborate below)
• Other Relationship
  Other Relationship
• Satisfaction*
  Please select a response indicating how satisfied or dissatisfied you are with New Hope Services:

  	Very Dissatisfied	Somewhat Dissatisfied	Neutral/No Opinion	Satisfied	Very Satisfied
  Response Time and Communication
  Knowledgeable Staff and Management
  Level of Respect and Professionalism
  Overall Quality of Client Services

• Referral Likelihood*
  On a scale of 1 - 10, how likely are you to refer someone to New Hope Services?

  1 - Not Likely At All	2	3	4	5 - Somewhat Likely	6	7	8	9	10 - Extremely Likely

• Improves Lives*
  Overall, do you feel that New Hope Services improves the lives of adults with disabilities?
  • YES
  • NO
  • N/A or Don't Know
• Increases community integration*
  Overall, do you feel that New Hope Services increases community integration for adults with disabilities?
  • YES
  • NO
  • N/A or Don't Know
• Provides important community services*
  Overall, do you feel that New Hope Services provides important and necessary services to the community?
  • YES
  • NO
  • N/A or Don't Know
• Feedback
  Please leave us feedback to better explain your responses above:
• Improvements we could make
  Please let us know if there are any processes, services, or improvements that you feel we could implement to enhance our current quality of care:
• CAPTCHA

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