Adult Client Services Satisfaction Survey

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Date
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Date
Client Name:*
Client Name
Name of Person Completing Survey*
Name of Individual Completing this Survey:
Services Used*
Which of the following services have you used with New Hope Services in the last 12 months?
- Supported Living/Residential
- Community (Group/Individual)
- Facility (Group/Individual)
- Wellness Coordination
- Employment Services
- Work Services/Workshop
- Behavior Management
- Hope SeniorCare
- Respite
- Participant Assistance and Care (PAC)
- Attendant Care/Homemaker)
- Transportation
Satisfaction*
For each area below, please select a response indicating how satisfied or dissatisfied you are with New Hope Services. (top description)
Very Dissatisfied Somewhat Dissatisfied Neutral/No Opinion Satisfied Very Satisfied
Responsiveness to your Needs
Treatment from Staff
Effectiveness of Services
Overall Quality of Services
Community Integration*
Overall, has New Hope Services increased your Community Integration?
- Yes
- No
- N/A or Don't Know
Independence*
Overall, has New Hope Services helped you become more independent?
- Yes
- No
- N/A or Don't Know
Quality of Life*
Overall, has New Hope Services enhanced your Quality of Life?
- Yes
- No
- N/A or Don't Know
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
General Feedback
Please leave us feedback to better explain your responses above and to let us know how we're doing.
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	Very Dissatisfied	Somewhat Dissatisfied	Neutral/No Opinion	Satisfied	Very Satisfied
Responsiveness to your Needs
Treatment from Staff
Effectiveness of Services
Overall Quality of Services

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Adult Client Services Satisfaction Survey

Adult Client Services Satisfaction Survey

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