CLIENT SATISFACTION SURVEY
Please complete this satisfaction survey to help us provide the supports and services you need. If you do not understand a question or are not sure about how to respond, ask someone to help you. Provide comments as needed. Return the completed form to the staff person who gave it to you.
Client	MONTH/YEAR
Services	SLC	PS-Day	PS-Qtr	LSD1	Other (specify)
AREA	Question	Unsure	Yes	No
General	Do you have a copy of your Support Plan and your Implementation Plan?
Are you able to state the goals you are currently working on?
Decisions	Do you have a guardian to help you make decisions in your life.
Do you have a representative payee to help you with financial decisions in your life?
Are you able to make as many decisions as you want to in your life?
Choice	Are you able to choose your own goals?
Does staff help you make informed choices?
Rights & Responsibilities	Do you have access to your personal things, your money, and food?
Do you know what your rights and responsibilities are in supported living?
HIPAA	Is your personal privacy considered by staff?
Does staff ask your permission before talking about your personal information?
Social Inclusion	Are you able to access all the community resources (stores, library, bank, movies, etc) you want to?
Does staff help you with going places and doing things you want to do in the way you can do them?
Do you feel your participation and/or independence in the community is where you want it to be?
Relationships	Do you socialize in any way with neighbors, friends, or family?
Are you connected to a natural support network (people who are not staff)?
Dignity & Respect	Are you treated with consideration by staff?
Does staff listen to your ideas?
Security & Continuity	Do you feel safe and happy where you live?
Do you feel like life is smooth rather than bumpy?
Resolutions	Do you know how to resolve conflicts?
Do you know how to report abuse?
Health & Safety	Do you have help making and keeping appointments (medical, dental, specialists) when you need to?
Do you know what to do in case of a big emergency or a small problem?
Expose, Educate, Experience	Does staff encourage you to try new things and experience life to its fullest?
Does staff help you to learn about, become familiar with, or try new things?
Have you learned new things from your staff?
Goal Choice & Progress	Do you choose your own goals?
Do you feel you have made progress on your goals?
Change	Do you know you can change your mind, your staff, your services, etc?
Are you happy with your staff and the services provided?
Do you know what to do if you are not happy with your services or goals and want a change?
Person-Centered Process	Does staff help you achieve goals that are important to you and also meet your needs?
Does staff help you achieve your goals by providing opportunities to expand life experiences?
Does staff "know" you and your significant others (family, loved ones, dear friends)?
Comments

Individual	Signature	Date
Individual
Form Completed By
Advocate/Guardian
Support Coordinator
Date sent to Support Coordinator	How sent to Support Coordinator