CUSTOMER SATISFACTION SURVEY

Please rate the quality of the House of G.R.A.C.E Residential Services, LLC

Homemaker Personal Care (HPC)/HPC Transportation Services -or- Provider contact you receive from us:

Date: ___________I am a:  CLIENT            SSA               PROVIDER           GUARDIAN             OTHER_______

1. When I talk with staff, they treat me with respect, dignity and worth.

Excellent

Good

Fair

Poor

2. Because of the services received from this provider, the client’s ability to meet his/her outcomes is:

Excellent

Good

Fair

Poor

N/A

 

3. The staff follow the Individualized Service Plan (ISP) and the quality of care is:

Excellent

Good

Fair

Poor

N/A

 

4. The staff meet and support all of the client’s needs:

Excellent

Good

Fair

Poor

 

5. The staff make me feel important:

Excellent

Good

Fair

Poor

6. The staff provide competent services:

Excellent

Good

Fair

Poor

 

7. Please rate our responsiveness to your questions/emails/calls/requests for information:

Excellent

Good

Fair

Poor

 

8. Please rate your overall satisfaction with our services:

Excellent

Good

Fair

Poor

9. Would you recommend us to friends/family/colleagues?

Excellent

Good

Fair

Poor

 

10. What else would you like to share with us?

Thank you for completing our survey!