CLIENT SELF-ASSESSMENT SURVEY
Discuss each section with the client, making sure he understands the concepts and using this as a training tool. Ask the client to describe how he honestly feels and to provide examples when possible. You may ask more questions to determine if the client understands what is being asked. Check "Yes" or "No" only one time for each section. Base the yes or no response on whether, in general, the client understands the area being discussed and feels the area is a positive (yes) or negative experience (no). Explain responses which require follow-up, that show a "No" response, or show a lack or problem in each area. The survey is used to provide quality services to the client.
Individual	Date
Staff
Services	SLC	PS-Day	PS-Qtr	LSD1	Other (specify)
Item	Yes	No
Is the client able to comprehend this survey and provide his own answers?

Does the client have a copy of his Support Plan and Implementation Plan?

Is the client able to state the goals he is currently working on?
1 Decisions Use the questions as a guide to determine whether the client makes his own decisions, has help in decision-making, or is "told" what to decide.
Do you have a guardian who helps you make decisions? Do you make your own decisions?

Do you have a health care surrogate who helps you with heath issues?

Do you have a living will?

2 Choice Use the questions as a guide to determine whether the client feels he has freedom of choice in all areas of his life that he wants. Provide examples when possible. Emphasize that the client can choose, within reason, goals, services, providers, routines, activities, etc. Determine whether the client feels that staff provide alternative choices that are explained and that the results (consequences) of those choices are understood.
Are you helped with choosing:

- where to live?	- where to bank?	- where to shop for clothes	- where to shop for groceries

- when and what to eat	- where to get your medicine	- where to worship?	- doctors/dentists/specialists/hospital?

- your supported living coach or other staff?

Do you know you can choose or change the person who provides your services?

Do you participate in community outings of your choice and when you want to?

Do you decide on your own goals?

Do you choose what you want to do during the day?

Do you choose what to do while you are receiving services?

Does your staff provide you with alternative (more than one) choices and explain them to you?

When you make a choice, does your staff try to help you understand the results of that choice?

Do you have freedom of choice in all areas of your life?

3 Rights & Responsibilities Use the questions as a guide to determine whether the client feels he is able to exercise his rights as a citizen and a developmentally disabled individual (Bill of Rights) and whether the client feels he understands his responsibilities.
Are you able to say what you feel even when others are trying to tell you what to do?

Does your service provider teach you about your rights and laws that protect you from people that treat you badly?

Are there things you would like to have that you are working towards getting?

Does staff encourage you to work towards your goals and dreams (staff does not say you are not "allowed" to have them or "can't" have them)?

Do you have access to your own personal things, money, food, etc?

Do staff knock on the door before they come in? Is there a place you can be alone when you want to?

Do you exercise your rights?

4 HIPAA Use the questions as a guide to determine whether the client understands HIPAA and whether he feels he is part of decisions made about his personal information. Determine whether the client understands that he does not have to provide anyone with personal information about himself (or about anyone else). Determine whether the client understands that to provide adequate services and to protect the client's health and ensure he is safe, that staff may need to know personal information. "If you your lips would keep from slips, of these five things beware: of whom you speak, to whom you speak, and how, and when, and where."
Does staff ask you (or guardian) for permission when your personal information is given to another person or agency?

Does staff direct comments to you (staff does not talk about you as though you are not there)?

5 Social Inclusion Use the questions as a guide to determine whether the client feels he is part of his community or working to be independent in his community.
Are you a member of a club or other organization (league, church, community association, etc)?

Are you able to access resources when you want to on your own without any kind of staff help?

Do you need staff to accompany you in the community to do things?

Do you feel your level of participation or independence in the community is where you want it to be?

6 Relationships Use the questions as a guide to determine whether the client understands the difference between acquaintances, friends, and loved ones and to determine the extent that the client has meaningful relationships or feels isolated.
Do you understand the difference between loved ones, acquaintances, and friends?

Do you have family or friends or other natural network who help you with anything or with whom you socialize?

Do you perform different social roles?

7 Dignity & Respect Use the questions to determine whether the client understands these concepts (dignity, respect) and whether he feels he is treated with dignity and respect (at home, in the community, by staff, by family, by friends).
Does staff treat you and talk to you like an adult?

Does staff show regard for your opinions and thoughts?

Do you feel like you are treated like anyone else in the community?

8 Security & Continuity Use the questions as a guide to determine whether the client understands these concepts and whether he experiences security and continuity in his life. Determine whether the client experiences constant change (staff, jobs, daily routines, etc) or whether he feels his life stays pretty constant.
Do you feel secure where you live and with whom you live?

Do you feel like things in your life are pretty even without big ups and downs each day?

Do you feel comfortable with the days and times staff (including WSC) work with you?

9 Resolutions - Complaints, Conflicts, Grievances, Abuse, Neglect, & Exploitation Use the questions as a guide to determine whether the client understands these concepts and what to do if he has problems of any kind. Determine whether the client feels he has problems that go unresolved and whether he feels he has help with resolving problems. Determine whether the client is learning about conflict resolution and what to do in case of abuse.
Do you feel like any problems (complaints of any kind) you have are resolved?

Do you feel like staff (including WSC) resolve issues in a timely, understandable manner?

Do you know how to report abuse, neglect, or exploitation if any of these things happened to you?

10 Health & Safety Use the questions as a guide to determine whether the client feels his personal health and safety are being addressed.
Do you feel like your medical issues are addressed in a timely manner?

Do you get to see your doctor, dentist, or specialist as often as you feel you need to?

Do you get annual exams?

Do you know what to do in case of fire or other emergencies at home or in the community?

11 Exposure, Education, Experience Use the questions as a guide to determine whether the client is exposed to new things (choices, alternatives, new ideas, etc), is learning about new things, and is actually trying out new things.
Have you done things or gone places that you never thought you would be able to do?

Have you pursued any diploma, degree, or continuing education that you would like?

Does staff encourage you to try new things and experience life to its fullest (learn about, do, or try new things)?

12 Goal Choice & Goal Progress Use the questions as a guide to determine the extent which the client decides his own goals (or whether someone else decides them for him) and whether the goals he decides on during planning are the actual goals he ends up with on his SP.
Do you decide on the goals you will work on each year (no one "tells" you what to work on)?

Are you happy with the goals you set for yourself each year?

Are the goals you set for yourself put into a report and given to your WSC before your support plan meeting?

Are the goals you get back on your Support Plan the same goals you told your staff and WSC that you wanted to work on?

Do you know what your goals are that you are currently working on?

13 Change Use the questions as a guide to determine whether the client understands that he is able to change his mind, his providers, his staff, his WSC, etc. Determine whether the client understands how to make a change.
Do you know what to do if you are not happy with your services, your goals, or your staff and want a change?

Do you make changes to your goal or does someone do that for you?

14 Person-Centered Planning Use the questions as a guide to determine whether the client feels his experience in this program is geared toward him, his ambitions, his goals, his dreams, and his hopes. Determine whether the client feels staff are responsive to his personal experiences and whether the client feels staff provide opportunities for relevant training and to expand the client's life experiences. NOTE: Person-centered planning is used to assist the client with using his own capacity and potential for constructive action to realize his goals. Staff act as facilitators rather than directors, offering respect, acceptance, and understanding to the client to help empower him to realize his own potential.
Does staff help you decide on and achieve goals that are most important to you or that meet your needs?

Does staff "know" you and your significant others?

Does staff provide services needed to achieve your goals by providing opportunities for relevant training or to expand life experiences?

Client Signature	Date