Client Satisfaction Survey Form

First Name

Last Name

1. Please rate the quality of the services you received from us:

Excellent

Good

Fair

Poor

2. Please rate the information we provided on our website:

Excellent

Good

Fair

Poor

3. Please rate our staff in terms of efficiency:

Excellent

Good

Fair

Poor

4. Please rate our responsiveness to feedback:

Excellent

Good

Fair

Poor

5. Please rate your overall experience with our services:

Excellent

Good

Fair

Poor

6. Would you recommend us to friends and family?

Yes

No

How long have you received Home Health Care services from Core Home Health Care?

In-Home Support Services

Independent living skills training

Supported Living Services for Adults

In-Home Family Support

Individualized Home Supports

Employment Services

Supported employment services

Employment development services

Employment exploration services

Employment support services

PCA

Personal Care Attendants

Other Service

United Health

Housing access coordination (HAC)

Department of Veterans Affairs Community Care Network (VA CCN)

Frequency of our services?

Reason:

Very Satisfied	Satisfied
Neutral	Unsatisfied
Very Unsatisfied

Very Satisfied	Satisfied
Neutral	Unsatisfied
Very Unsatisfied

Very Satisfied	Satisfied
Neutral	Unsatisfied
Very Unsatisfied

Very Satisfied	Satisfied
Neutral	Unsatisfied
Very Unsatisfied

Very Satisfied	Satisfied
Neutral	Unsatisfied
Very Unsatisfied