Customer Satisfaction Survey
Who is completing this survey?
INW customer
INW customer with help from a trusted family member
INW customer with help from a trusted friend
INW customer with help from a trusted provider
Name of INW customer (First and Last)
Who is your Personal Agent at Independence Northwest?
Adrienne Akin
Andrea Ochsner
Angie Frank
Bernice Celino
Chris Psota
Clover Mow
DJ Rayley
Haley Hiatt
Jamie Osborn
Jesse Raposa
Jill Putnam
Joe Connell
Katie Dalton
Kirsten Lawrence
Megan Dart-McLean
Mia Prohaska
Michelle Dorantes
Paul Kuenzi
I'm not sure
How often do you communicate with your personal agent?
More than once a week
Monthly
About once a week
Quarterly
A couple times a month
Other (please specify)
Comments:
Are you happy with how often your Personal Agent connects with you?
Yes
No-I'd like to communicate MORE often
No-I'd like to communicate LESS often
Comments:
What's your favorite way of connecting with your Personal Agent
Video chat
Phone
Email
Text
In person
What's your favorite way of connecting with your Personal Agent?
Video chat
Phone
Email
Text
In person
Comments:
Do you get the supports you need from INW?
Yes
No
Sometimes
Prefer not to answer
Don't know
Comments:
Do you feel supported by your PA?
Yes
Sometimes
No
Don't know
Prefer not to answer
Comments:
INW is here to help you get connected to the supports you need. Are there unmet needs you have right now that you'd like our help with?
How would you rate your happiness with your services from Independence Northwest
5-Very Satisfied
4-Satisfied
3-They're Okay
2-Somewhat Dissatisfied
1-Very Dissatisfied
Do you have any other feedback you'd like to share with us about your experience as an INW customer?
Can we use quotes from your survey on our website and other materials?
Yes
No
Should we keep the quote anonymous or can we use your name?
Anonymous
With name
If you would like your PA or a member of our team to follow up with you on outstanding questions or concerns, please include your name and the best way to contact you (phone or email), and we will be in touch soon.
Would you like to be added to our mailing list to receive information about resources, events, and important updates or changes to services?
Yes
No
If you answered yes above, please include your email address
If there are members of your support circle that you would like us to include on this mailing list, please include their names and emails below
Submit
Should be Empty: