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* 1. Date Completed

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* 2. What is the age range of the person who receives services?

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* 3. Survey completed by:

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* 4. Overall how satisfied are you that Aspire supports you in pursuing your life goals?

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* 5. How satisfied are you with the quality of Aspire's services?

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* 6. Overall how satisfied are you with the staff at Aspire?

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* 7. Are you comfortable with expressing concerns to Aspire staff?

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* 8. Are you satisfied that Aspire staff address your concerns?

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* 9. Is/Are the service(s) you receive from Aspire what you expected?

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* 10. Does the service(s) you receive from Aspire meet your needs?

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* 11. Did you participate in creating your Person Centered Plan?

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* 12. Who was involved in assisting you in your Person Centered Planning (check all that helped you)?

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* 13. Does your Person Centered Plan address what is important to you?

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* 14. Does your Person Centered Plan address what you need?

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* 15. Do you have the proper adaptive equipment available to meet your needs?

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* 16. How often does Aspire staff provide information to you in a way you understand?

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* 17. If you would like a personal response to your comments, please leave your name and phone number below.

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* 18. If you are interested in receiving surveys electronically, enter e-mail address below.

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