CLIENT/FAMILY SURVEY
What service(s) do you/your family member receive with our agency?
Rows
Please select all that apply
Personal Care
In-Home Respite
Adult Companionship
Homemaker Services
How long have you/family member been with our agency? Mark all the apply
Rows
Never used
Less than 1 month
1-3 months
3-6 months
6 months - 1 year
More than 1 year
Personal Care
In-Home Respite
Adult Companion
Home Maker Services
How satisfied are you with our service?
Rows
Very Unsatisfied
Unsatisfied
Neutral
Satisfied
Very Satisfied
Quality
Client Care
Program Monitoring
First time experience
What qualities are you most satisfied with?
What qualities are you least satisfied with?
Does our service meet your expectations?
*
Yes
Other
Is our staff courteous and attentive?
*
Yes
Most times
Not often
Other
How likely are you to refer our services?
*
1
2
3
4
5
Never
Definitely
1 is Never, 5 is Definitely
How satified are you with us in the areas listed below?
Rows
Very Satisfied
Satisfied
Somewhat Satisfied
Not Satisfied
Service Quality
Staff Availability
Communication
Respectful and Helpful
Additional comments
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