Clone of DVA HHS SERVICE SET UP FORM

1
Client and Account Information* This field is required.Please provide the client's details and your requested final date of service so we can accurately locate your account and begin the transition process.
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Please Select
Myself
Someone Else
I am completing this form on behalf of:
What date would you like services to cease?
Full Name
Contact Telephone Number / Mobile
Please enter your email
What is the address your services have been previously provided at
2
Third Party Contact Info* This field is required.Please provide your details, if you are completing this form on behalf of someone else.
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Please Select
Spouse
Parent/Guardian
Plan Co Ordinator
Plan Nominee
Other
Your relationship to the client
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Please Select
Yes
No
Has the client requested you to cancel this service?
Your Name
Your Contact Telephone Number
Please enter your email
3
Reason for Cancellation* This field is required.We are always working to enhance our support. Please let us know the primary reason for your departure so we can better understand your circumstances and our areas for growth.
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Services are no longer required (e.g., recovery, change in personal circumstances)
Relocation out of AkinCare's service area
Financial reasons / funding changes
Transitioning to a different service provider
Dissatisfaction with care or service quality
Dissatisfaction with administrative or communication processes
Client has passed away or moved to full-time residential care
Other (please specify)
What is the primary reason for cancelling your services with AkinCare?
Please share any additional details about your reason for leaving.
4
AkinCare Experience Survey* This field is required.Please use the emoji slider to rate your satisfaction with the following four areas of your AkinCare experience
Quality Of Your Support Worker
Scheduling and Reliability
Office Communication and Support
Overall AkinCare Experience
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Quality Of Your Support Worker
Scheduling and Reliability
Office Communication and Support
Overall AkinCare Experience
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5
Feedback* This field is required.Your candid feedback is vital to our team. Please take a moment to share what went well during your time with us and where we can improve our standards of care for future clients.
Is there anything AkinCare did well during your time with us?
Do you have any feedback or ideas on how we could improve our services?
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Please Select
1 - Absloutely
2 - Possibly
3 - Maybe
4 - Probably Not
5 - Not at all
How likely are you to refer AkinCare to a friend or family member?
6
Next Steps and Authorisation* This field is required.Please review the statement below and confirm your acceptance
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