Overall Satisfaction

OVERALL SATISFACTION
1. Given all the considerations, how satisfied are you with your
consumer directed support program?
V e r y
satisfied
Neither satisfied
nor dissatisfied
dissatisfied
• ' Q • • • • •
Very Neither likely Very
2. Hcjw likely would you be to recommend a consumer directed ^p- noru
f' ke y unli
' | keIy
support program in your county to a friend in a similar situation? .. jjjjf [] Q Q Q Q Q
3. Ha's the consumer directed support program met the expectations Exceeded Met Failed
. . . , , , . . Expectations Expectations Expectations
that were set for you by your case manager and county social ~~r—; "-i ^
Services department? V> 3 • Q • • • •
4. What is the one thing that would have the greatest impact on your satisfaction with consumer directed
supports? ;
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Thinking ig beyond consufnsr consurngr directed supports to your overall quality of life, life;-on on the following followir pages
please indicate how much you agree or disagree with each statement. Please complete these sections
from the perspective of the person with a developmental disability. The person who has the
developmental disability should oe directly involved in completing this survey as much as possible.
INDEPENDENCE I Mobility/Control/Privacy Agree Disagre
Strongly Somewhat Neither Somewhat Strongly
1. I can (even if someone helps me because of my disability) get
to where I want to go. .. .
2. I have control over mv daily schedule
3. I have privacy to be alone or with people I choose.
4. Only people who are supposed to know my personal
information have access to it
V
5. I can set desired outcomes (goals) for myself
6. I can
7. I can
8. I am ;
V
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a a ar • •
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