Which of the following services you received in the past year?:



Can the individual receiving services communicate enough to successfully complete this survey?:

(if no, do not complete form)
Do you feel safe at your program services?:

Do you know your rights and are you treated fairly?:

Are you free from Abuse, Neglect, and Exploitation (ANE)?:

I want to change one or more of my program services.:

(If yes, a choice form will be mailed out)
Are you satisfied with your case management services?:

Are you satisfied with your day services?:

Leave answer blank if not receiving this service.
Are you satisfied with your residential services?:

Leave answer blank if not receiving this service.
Today
Today