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1. Please select the response that most closely reflects your experience.

Dissatisfied Neutral Satisfied N/A
My phone calls, emails and other communication are returned in a reasonable amount of time.
My provider has a very high quality of care.
My provider has up to date equipment and facilities.
Before I chose the provider, I expected the provider to meet my needs.
Before I came to the provider, I expected quality care.
Appointments and meetings are scheduled when needed and my availability is considered.
Medications and health care issues are explained to me in a way I can follow.
Compared to other local providers, this provider provides the best care.
The staff try their best to help me if there is a problem.
I can usually get my questions answered when I call the provider.
I was given the chance by my provider to provide input in decision making.
I feel safe in the facility.
I would recommend this provider without hesitation.
I am satisfied where I live.
I am satisfied who I live with.
I am satisfied with my day program choices.
I have no significant complaints or dissatisfaction with my provider.

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2. Your feedback is vital to maximizing our quality of care for future individuals like you. Please use this space for additional comments.

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3. If you are not satisfied with our services and would like to be contacted, please provide your contact information.

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