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* 1. Do you receive services from us?

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* 2. The main services I receive include (you can select more than one service):

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* 3. The main services I receive are attached to the following Program (Select one):

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* 4. What State or Territory are you located in?

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* 5. The team that deliver services to me are located in?

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* 6. Please choose the goals that best describe why you receive our services? (You can choose more than one)

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* 7. Have we assisted you in progressing towards or meeting each of your individual goals?

  Yes No Unsure Not Applicable
To maintain or extend my capacity to live independently in my own home
To progress towards living more independently (whether living alone, in a partnership, in a family or group environment)
To improve my health and wellbeing
To improve my social and community participation

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* 8. Please tell us whether you agree / disagree with the following statements?

  Agree Neutral Disagree Not Applicable
The initial sign up process was efficient and well co-ordinated.
I am satisfied with the time it took to receive any new services.
Office workers are respectful of my choices and decisions.
Services are flexible to meet changes in my health or personal circumstances (e.g. social leave).
My service coordinator responds to my requests within a reasonable time frame.
I am always informed in a timely manner about cancellations or changes to my services.
I am satisfied with the quality of service I receive from Office Workers.

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* 9. Please tell us if you agree / disagree with these statements about your Support / Care / Service Plan :

  Yes No Unsure Not Applicable
I have a Support Plan, Care Plan or Service Plan.
I was involved in creating my Plan.
My Plan reflects my current needs (it is accurate and up to date).
My Plan is easy to understand.
My support worker is aware of my Plan and follows it.
My Plan is reviewed at least every year.
As per my wishes, my family / friends / carers / guardians are involved when updating my Plan.

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* 10. Please let us know if you agree / disagree with these statements about your Support Worker:

  Agree Neutral Disagree Not Applicable
Support workers are respectful of my choices, decisions, health & personal circumstances.
Support workers have been appropriately trained to meet my needs.
I can rely on regular and consistent services.
My support worker arrives when they are supposed to.
My support worker stays for the duration of the service.
The services I receive have improved my quality of life.

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* 11. Do you agree or disagree with the following general statements?

  Agree Neutral Disagree Not Applicable
I know the process to give feedback or make a complaint.
I have received, or I believe I would receive fair treatment if I made a complaint.
The monthly invoices I receive (if relevant) are timely and accurate.
The monthly invoices I receive (if relevant) are easy to understand.
The monthly statements I receive (if relevant) are timely and accurate.
The monthly statements I receive (if relevant) are easy to understand.

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* 12. Do you have any additional feedback?  If yes, please feel free to provide below:

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* 13. Are happy for us to contact you to discuss your feedback?  If yes, please include your Name and Contact Details below.

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