Instructions - The following questions can be answered by clicking the buttons preceding Yes, No, or N/A if you feel that a question is not applicable to you. A space is provided below each question for additional comments. Please let us know if there is something you feel we have left out. If you wish to be contacted regarding any of your responses indicate this below and provide us with your phone number. Thank you for taking the time to respond.
Consumer Name: (optional)
Person Assisting with Completion of Survey: (optional)
Service Coordinator: (optional)
Questions:
1. Has your Service Coordinator explained his/her role to you and how they may be able to assist you?
Yes
No
N/A
Comments:
2. Has your service coordinator involved you in planning for what you want and/or need in the present and future?
Yes
No
N/A
Comments:
3. Has your Service Coordinator provided you with a copy of your Individualized Service Plan (ISP)?
Yes
No
N/A
Comments:
4. Does your Service Coordinator spend time with you, getting to know who you are and what you want/need?
Yes
No
N/A
Comments:
5. Does yor service coordinator talk with you about how they may assist you with accessing the programs, services or supports you want/need?
Yes
No
N/A
Comments:
6. Does your Service Coordinator assist you in getting answers to your questions; assist you with resolving problems or satisfying needs as they come up?
Yes
No
N/A
Comments:
7. Does your Service Coordinator seem to be informed and knowledgeable about the various community supports and services?
Yes
No
N/A
Comments:
8. Do you think your Service Coordinator pursues your needs/interests in a timely manner?
Yes
No
N/A
Comments:
9. Is your Service Coordinator aware of the services and supports you receive?
Yes
No
N/A
Comments:
10. When you have told your Service Coordinator that you are not happy with a particular support or service, has he/she assisted you with resolving any issues?
Yes
No
N/A
Comments:
11. Do you know that you can call the Service Coordination Department for consultation in an emergency after working hours, weekends or holidays?
Yes
No
N/A
Comments:
12. Do you think your Service Coordinator has made a reasonable effort to assist you to pursue your desired activities and to receive needed supports?
Yes
No
N/A
Comments:
13.Are you happy with the support your Service Coordinator provides you?
Yes
No
N/A
Comments:
Please use the space below to write what you think about the job your Service Coordinator is doing:
Please use the space below to write down your ideas/suggestions of how your Service Coordinator could do a better job:
Thank you in advance for your cooperation and assistance with this review.
