Consumer Satisfaction Survey
Consumer Name:
First Name
Last Name
1. Do you feel safe at home and when you are out in the community?
Yes
No
2.Do you get to make choices about how you spend your money?
Yes
No
Tell us about a choice you recently made:
3. With the money you have, where was the last place you chose to go or the last thing you chose to purchase?
4. Is your coach teaching you things that you want to learn? (Examples: cooking, grocery shopping, paying bills)
Yes
NO
5. Do you get help from your support staff when needed?
Yes
NO
6. Do the staff listen to you and treat you with respect?
Yes
NO
7. Did you get a say in picking the place you live and who you live with?
Yes
NO
8. Do you feel you can make a complaint if you are unhappy about something?
Yes
NO
Who would you call to make a complaint?
9. Do you feel your privacy is protected?
10. In general, are you satisfied with your support services?
Yes
No
Consumer Signature:
Continue
Continue
Should be Empty: