Overall Satisfaction

O V E R A L L Satisfaction §
• _ _ _ _ _ B _ _ B B H B — • • M M M A M M M M A D M v Neither satisfied
satisfied nor dissatisfied Very
. Given all the considerations, how satisfied are you with your ~~ «
consumer directed support program? Q _ Q Q Q Q Q
Very Neither likely v
. How likely would you be to recommend a consumer DIRECTED noruniikeiy u n l i k e
support program in your county to a friend in a similar situation? .. Q Q Q fj Q Q Q ~
. Has the consumer directed support program met the expectations Exceeded Met F a i i e d
that were set for you by your case manager and county social
E ; ? t a t i o n s
Pf
Expectations Expectation.
services department? rj Q rj Q Q [_
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• Tpports? " 9 h a t W
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h e 9 r e a t e s t i m p a c l o n
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satisfaction with consumer directed
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|jhinking beyond consumer, directed supports to your overall quality of life, onJteJoHowing pages
fpldase 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 be directly involved in completing this survey as much as possible.
Independence I Mobility/Control/Privacy Agree D
! sag
'!L ,
* I * Strongly Somewhat Neither Somewhat Strongly
I can (even if someone helps me because of my disability) get
to where I want to go •
2. I have control over my 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
5. I can set desired outcomes (goals) for myself.
6. I can decide about how I spend my money ...
I can make decisions that will affect my future.
I am satisfied with my current level of indepen<
• • a • •
a • • •
• • y • •
• a •
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• a •
• • • •
a • • a
y
l y