1. Thank you for taking the time to complete this survey. Your feedback is important to us.

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* 1. Your Name (optional)

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* 2. Program Name (Program Director):

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* 3. Address where the individual lives 

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* 4. How strongly do you agree with each statement

  Strongly Agree Agree Neither agree or disagree Disagree Strongly Disagree N/A
The house is comfortable, and homelike
The home is clean and well kept
The home is well maintained (ie windows working, appliances in good repair)
The house location is in a safe and clean neighborhood
My family member/ward is able to access the community easily
The furnishings & decorations are reflective of my family members/wards taste
I am happy with supports REACH provides to my family member/ward
Medical/medication concerns are addressed timely
My family member is educated and offered healthy food choices and participates in menu planning / cooking
My family member has a full life regarding the choice of leisure activities
My family member looks clean/neat and is comfortable with themselves
My family member reports happiness with their roommate
My family member is helped when frustrated or anxious
My family member is provided excellent overall care
My family member is challenged to their to their fullest potential
The Program Director is easily accessible
The Assistant Program Director is easily accessible
Communication with the management team is adequate
I am kept up to date with financial information about my family member/ward (if authorized to receive info) 
Direct Care Support Staff are caring and well trained in my family members strength and weaknesses
I am confident in the ability of the direct care support staff to work with my family member/ward
I have confidence in staff to relay information to program management
I have confidence in the REACH administrative (office) staff
I would be interested in attending a staff meeting on occasion to discuss my family member/ward and offer input to the staff
I have confidence with the Emergency - 24 hour on call system
I receive information /documentation about medical appointments (if authorized to receive) 

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* 5. Other Comments?

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