Placement Satisfaction Survey

Thank you for considering Support, Inc. We strive to provide the best services possible. We hope you will take a few minutes to complete this survey to help us look at areas we may need to improve. Once you have taken the survey, we will send you a $25 gift card in appreciation of your time.

Please indicate(using the ranking system provided after each question)if this area was a factor or non-factor in your decision making process.

Question Title

* 1. The Support, Inc. Behavioral Services department and the professionally qualified staff were a value added benefit for our family member.

Extremely Important, a major factor in choosing Support, Inc.

Very Important

Important

Slightly Important

Not at all Important, a major factor in not choosing Support, Inc.

Does not apply

Other (please specify)

Question Title

* 2. The Support, Incorporated Nursing services department and the professionally licensed staff were a value added benefit for our family member.

Extremely Important, a major factor in choosing Support, Inc.

Very Important

Important

Slightly Important

Not at all Important, a major factor in not choosing Support, Inc.

Does not apply

Other (please specify)

Question Title

* 3. The host home provider(s) we met was/were a good match for our family member.

Extremely good match, major factor in choosing Support, Inc.

Very good match

Moderate match

Not a good match, major factor in not choosing Support, Inc.

Not Applicable, no providers were met

Please explain why match was or was not a good fit (ex. floor plan, home location, etc):

Question Title

* 4. The Placement department (Cindy and Kristin) were knowledgeable and attentive to our needs and the needs of our family member and we felt comfortable with them assisting us in the placement process.

Extremely Comfortable, major factor in choosing Support, Inc.

Very Comfortable

Comfortable

Somewhat Comfortable

Extremely Uncomfortable, major factor in not choosing Support, Inc.

Comments:

Question Title

* 5. We were aware of the excellent reputation Support, Inc. has as a service agency.

Extremely Aware, a major factor in choosing Support, Inc.

Very aware

Aware

Slightly Aware

Not at all Aware

Comments:

Question Title

* 6. The CCB case manager or resource coordinator was a factor in choosing Support, Inc.

Extremely Important, a major factor in choosing Support, Inc.

Very Important

Moderately Important

Somewhat Important

Not At All Important,a major factor in not choosing Support, Inc

Not Applicable

Other (please specify)

Question Title

* 7. Were there other staff at Support, Inc. you met who were influential in helping you make your decision?

Yes

Please explain if you met other staff, how did that encounter assist you in making a decision (positve or negative interactions):

Question Title

* 8. Support, Inc.'s day program was a factor in choosing residential services for our family member.

Extremely Important

Very Important

Moderately Important

Somewhat Important

Not at all Important

Support's day program is not appropriate for our family member

Please explain:

Question Title

* 9. Were there other factors which were influential in helping you make your decision in choosing residential services?

Extremely likely

Very likely

Moderately likely

Slightly likely

Not at all likely

What one factor swayed you to choose or not choose Support, Incorporated (ie. friendliness, professionalism, knowledgable, phone calls returned/not returned, added services, etc...)

Question Title

* 10. How likely are you to refer Support, Inc. to others who may be looking for services?

Extremely Likely

Very Likely

Likely

Somewhat Likely

Not Likely

Comments:

Question Title

* 11. Please provide your mailing address and we will send your $25 gift card within one business day of completion of the survey!

Name:

Address:

City/Town:

State:

ZIP: