Family/Client Service Interest Survey #2

1.Tell us about you...

Name (Optional)

Email Address (Optional)

Phone Number (Optional)

2.I am a:

Client

Parent/Family Member

Service Provider

Community Member

7.Please provide any additional comments you may have on the services selected.

8.Are there other areas or options that you feel are lacking in the community?

Other (please specify)

9.Are you using all of your FDLRC approved services?

Yes

No

10.If you answered no to question 9, why have you not used your approved services? (Check all that apply)

Service provider does not have staff available to provide the service.

I am on a waitlist for the service.

Service provider does not have a bilingual staff available to provide the services.

Service provider cannot provide services during the time/s that I need it.

My work/family schedule makes it hard for me to participate in the service.

I stopped in-person services due to COVID and remote services do not work for our family.

I have services from other sources such as In Home Supportive Services, Department of Rehabilitation, my child’s school, and/or my private health insurance, which currently meet the needs of myself/my family at this time.

Not applicable to me

Other (please specify any other services not being used and why)

11.Are there any other things that would help you to be more successful?

Family/Client Service Interest Survey #2

Tell us what you need...