For each item, mark the response that best matches your opinion.
Accessibility in our case is defined as the degree to which a service or environment is available to as
many people as possible. It goes beyond the ability to just physically walk into a building or office.

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* 1. Today's Date

Date

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* 2. Survey Respondent

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* 3. Location

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* 4. Architectural

(Physical / Architectural Barriers may include barriers that prevent access to a building for an individual
who uses a wheelchair, doorways that need to be widened, or bathrooms that need to be made accessible. Physical barriers may be identified in the home, or in the community.)

  Strongly Agree Agree Disagree Strongly Disagree Not Applicable
I have had no difficulty in accessing the facility, including sidewalks, ramps, and exterior doors.
All sidewalks to the facility have curb cuts and are compliant with the 36" wide requirement.
All ramps are compliant with ADA requirements, painted, and have non-slip strips on every ramp

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* 5. Environment

(Environmental barriers may be any location or characteristic of a setting at home or in the community
which compromises, hinders or impedes service delivery and the benefits to be gained. This may include temperature controls, lighting or window shades which are easily controlled by those being served. Barriers may also be present for those sensitive to
light, noise, smells or with environmental sensitivities/allergies.)

  Strongly Agree Agree Disagree Strongly Disagree
The temperature in the facility is appropriate for my needs.
Offices, both administrative and clinical, are soundproof to the extent that privileged conversations cannot be heard by others.

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* 6. Attitudes

(Attitudinal barriers may include any preconceived opinions of the agency, the staff or of persons served which
impact client programming. Attitudinal barriers may include the use of language or terminology used in agency literature or while communication with stakeholders, or the person served. They may also include the community’s pre-conceived notions about the population served that might inhibit participation in programming. Cultural attitudes may impede participation, as well. Attitudinal barriers may minimize the input of the client, or may be impacted by whether or not the organization views the person served as a valuable individual with independent thoughts.)

  Strongly Agree Agree Disagree Strongly Disagree N/A
Input through satisfaction surveys and other forms of communication is solicited by this organization.
The staff has extensive knowledge and understanding of the treatment issues.

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* 7. Finances

(Financial barriers are indicated by insufficient funding for services/supports which enable the client to access
programming. Financial barriers may be overcome by advocating for more funding, or by raising money for the support of a service or the person served.)

  Strongly Agree Agree Disagree Strongly Disagree
As a client of this organization, I believe that the fees requested are justified.

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* 8. Employment

(Barriers to employment are identified as situations, occurrences or expectations which prevent the person
served from gaining meaningful employment and may include discriminatory employment practices, no flexibility in working
conditions or no review of requests for reasonable accommodations. Barriers can be removed using adaptive technology, flexible scheduling or other strategies which allow for more productive workplaces, and more satisfying settings for employees.)

  Strongly Agree Agree Disagree Strongly Disagree N/A
As a client, because of my disability / disorder, I have realized minimal barriers to my being employed or underemployed.

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