Member Entrance Survey Question Title * 1. What is your gender? Female Male Question Title * 2. What is your age? 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 or older Question Title * 3. Time in Program Less than 3 months 3,4,5 months 6,7,8 months 9,10,11motnh 1 year to 2 years Greater than 2 years Question Title * 4. Survey was completed with help from whom Help from no one Help from a friend Family assistance Help from a Staff person or Caregiver Question Title * 5. I am satisfied with the referral process ( Locating Services ) Strongly Disagree Disagree Agree Strongly Agree Don't Know , Does Not Apply Question Title * 6. The Staff did a good job in reference to customer service Strongly Disagree Disagree Agree Strongly Agreee Don't Know Does not Apply Question Title * 7. All my questions were answered during intake Strongly Disagree Disagree Strongly Agree Agree Don't Know , Does Not Apply Question Title * 8. Overall, are you satisfied or dissatisfied with the customer service you received from our company? Extremely satisfied Very satisfied Somewhat satisfied Not so satisfied Not at all satisfied Question Title * 9. How likely are you to recommend our service to others? Extremely likely Very likely Moderately likely Slightly likely Not at all likely Question Title * 10. How strongly do you recommend our company? Extremely strongly Very strongly Moderately strongly Slightly strongly Not at all strongly Question Title * 11. I was treated with with dignity and respect Strongly Disagree Disagree Agree Strongly Agree Don't know Does not Apply Question Title * 12. Please provide Us with comments and Feedback about the services your your received. Done
