Overall Satisfaction

Overall Satisfaction _
Neither satisfied
nor dissatisfied
satisfied dissatisfied
1. Given all the considerations, how satisfied are you with your ' ^ ' '
consumer directed support program? — y@ '—I LJ LJ U LJ
y*i Very Neither likely Very
2. How likely would you be to recommend a consumer directed
Thinking beyond consumer^djrected^supports tqyour overajl quality of life, on the following pages
please indicate how" much you^ree'ordisagree with each statement. Please complete thes^sections
from the perspective of the person with a developmental disability. The person who has the
developmental disability should pe directly involved in completing this survey as much as possible.
Independence | Mobility/Control/Privacy Agree Disagree
f • Strongly Somewhat Neither Somewhat Strongly
I can (even if someone helps me because of my disability) get m
to where I want to go ?. • 5} • • •
2. I have control over my daily schedule
• • • •
3. I have privacy to be alone or,with people I choose _ Q Q Q
v
4. Only people who are^upposed to know my personal
information have access to it. Q Q JQ Q Q
5. I can set desired outcomes (goals) for myself Q CJ JQ Q Q
6. I can decide about how I spend my money Q Q XlJ Q Q
7. I can make decisions that will affect my future F_ Q Ij ~\ ~\
8. I am satisfied with my current level of independence _\ _\ _\ _\
V e r y
noru
f' kely
support program in your county to a friend in a similar situation? . . j^Q Q [] Q Q Q
3. Has the consumer directed support program met the expectations Exceeded Met Failed
, i , . , . . . , Expectations Expectations Expectations
that were set for,you by your case manager and county social ~n—— ^-i ^
services department? • IB • • • • •
4. What is the one tiling that would have the greatest impac^on your satisfaction with consumer directed
supports?
V e r
y