 By completing this survey, you are letting us know your feelings about the services you received. If you need communication assistance, please call 7-1-1. If you need assistance in completing this survey, please call (307) 777-7191 and ask for Stephanie. |
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| Which of the following groups provided your Independent Living (IL) services? |
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| Could the IL Center or program better serve your needs? |
Any comments?
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| Please select at least two of the following services received: |
Other Individual Services (List all; Separate multiple items with a comma)
Other Training Services (List all; Separate multiple items with a comma)
Other Equipment (List all; Separate multiple items with a comma)
Referral to Other Agencies (List all; Separate multiple items with a comma)
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| Did you receive the information you requested? |
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| Was the information you received clear and understandable? |
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| Please list at least one specific way in which you were more independent than when you first contacted the IL staff: |
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| Would you recommend your IL Center or program to a friend with a disability? |
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Please rate your level of satisfaction with the following items: |
| The time it took to begin services: |
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| Overall satisfaction with services: |
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| I had a major role in planning of my services: |
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| My specialist was willing to listen to my ideas: |
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| My specialist was friendly: |
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| My specialist was knowledgeable: |
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| My specialist was able to meet or speak with me when needed: |
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| My specialist promptly returned my phone calls: |
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| My specialist referred me to other agencies and resources to better meet all of my needs: |
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| My specialist has the ability to take action in response to my needs: |
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| My specialist answered all of my questions: |
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| Completing the paperwork was easy: |
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| I would refer others for these services: |
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| I am aware that if I have unresolved questions/ problems, I could speak with the Director or contact CAP: |
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Optional Information |
| If you would like someone to contact you, please include your name and address. All contacts will be kept confidential unless otherwise requested. |
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| Name: |
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Address:
(Street, City, State, Zip) |
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