Adult Client Services Satisfaction Survey

Adult Client Services Satisfaction Survey

• Date
  MM slash DD slash YYYY
  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.
• CAPTCHA

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