2016 Personal Outcomes Survey

The Center for Family Support is committed to providing supports to individuals with disabilities and to the family members who care for them. It is our mission to provide quality services so that individuals can live the lives they want.

We are trying to find out if you like our services and if they are helping you. We will use this information to improve our programs. Your answers will be kept confidential.

If you are helping someone to complete this survey, please answer from their perspective.

Question Title

* 1. Providing your contact information is optional.

Name:

Address:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

Question Title

* 2. I am:

An individual receiving services

A family member/advocate

Question Title

* 3. I receive services in:

New York

New Jersey

Question Title

* 4. The services I get from Center for Family Support include (check all that apply):

Residential

Day Program

Medicaid Service Coordination

Community Habilitation

Respite

Home Care

TBI HCSS Services

ISS Services

Self Directed Services

Question Title

* 5. Do you like the services you receive from The Center for Family Support? (choose all that apply)

	Almost Always = 100%	Sometimes = 50%	Almost Never = 0%	N/A
Residential	Residential Almost Always = 100%	Residential Sometimes = 50%	Residential Almost Never = 0%	Residential N/A
Day Program	Day Program Almost Always = 100%	Day Program Sometimes = 50%	Day Program Almost Never = 0%	Day Program N/A
Medicaid Service Coordination	Medicaid Service Coordination Almost Always = 100%	Medicaid Service Coordination Sometimes = 50%	Medicaid Service Coordination Almost Never = 0%	Medicaid Service Coordination N/A
Community Habilitation	Community Habilitation Almost Always = 100%	Community Habilitation Sometimes = 50%	Community Habilitation Almost Never = 0%	Community Habilitation N/A
Respite	Respite Almost Always = 100%	Respite Sometimes = 50%	Respite Almost Never = 0%	Respite N/A
Home Care	Home Care Almost Always = 100%	Home Care Sometimes = 50%	Home Care Almost Never = 0%	Home Care N/A
TBI HCSS Services	TBI HCSS Services Almost Always = 100%	TBI HCSS Services Sometimes = 50%	TBI HCSS Services Almost Never = 0%	TBI HCSS Services N/A
ISS Services	ISS Services Almost Always = 100%	ISS Services Sometimes = 50%	ISS Services Almost Never = 0%	ISS Services N/A

Comments:

Question Title

* 6. Do you have a say in choosing the services or programs you receive?

Almost Always = 100%

Sometimes = 50%

Almost Never = 0%

Comments: