Provider Satisfaction Survey

Unity of Indiana has the privilege to provide case management services to individuals exercising choice in waiver services. Direct and open feedback from all stakeholders provides Unity of Indiana the opportunity to always increase the level of quality services being delivered. The form below allows you openly comment on your experience with our organization. Thank you for taking time as we value your invested input.

Full Name (Optional):

First NameLast Name

Date:

MonthDayYear

	Very satisfied	Satisfied	Neutral	Unsatisfied	Very unsatisfied	N/A
Overall, how satisfied is your organization with the Unity of Indiana case management services that the consumer or consumers you provide services to is receiving?

Comments (Optional):

	Definitely	Probably	Not sure	Probably not	Definitely not
Does your organization receive prompt response and follow up from all Unity of Indiana staff?

Comments (Optional):

	Less than a month	1-6 months	7-11 months	1-3 years	Over 3 years	Never used
How often is your organization in contact with the Unity of Indiana staff?

Comments (Optional):

Are Unity of Indiana’s staff and services easily accessible to you?

YesNoOther

If other, please explain:

"Unity of Indiana is committed to ensuring that its services and offices are accessible to people with disabilities. Such commitment applies equally to all persons, whether clients, their family or team members, employees, or members of the public." Are there any barriers to you being able to access Unity of Indiana"s services or offices?

YesNoOther

Does the Case Manager complete the 90 day checklist in the meetings?

YesNoOther

Comments:

Has the Case Manager had to create and complete a 90 day rememdation plan with your company?

YesNoOther

Comments:

Do you have any concerns with the services of any Unity of Indiana Case Managers? If yes, please explain.

What suggestions do you have to improve Unity of Indiana Case Management services?

Individual name, Title, and Employer completing this survey:

Comments:

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