Participant Survey – Advocate Centered Services Inc

Please answer the following questions honestly and to the best of your knowledge. We strive to provide the best services for our consumers. This survey greatly helps us to do so.

If you are unable to complete this form and require assistance, you may call the Corporate Office Reception toll-free at 1 (844) 855 0027 (option 1).

Personal Information

Name(Required)

Email(Required)

Phone(Required)

Today's Date(Required)

County of Residence(Required)

Relationship to Participant(Required)

Additional Participant Name

First Last

Service Coordination Entity & Service Coordinator (SC)

Overall, are you satisfied with your current Service Coordination agency?

Yes	No	Not Applicable	I do not Understand

Comments

Were you given a choice of Personal Assistance Services (PAS) providers?

Yes	No	Not Applicable	I do not Understand

Comments

Overall, are you satisfied with your SC?

Yes	No	Not Applicable	I do not Understand

Comments

Did you assist in developing your Individual Service Plan (ISP) with your SC?

Yes	No	Not Applicable	I do not Understand

Comments

Does your SC contact you on a quarterly basis?

Yes	No	Not Applicable	I do not Understand

Comments

Does your SC assist in resolving issues and/or concerns?

Yes	No	Not Applicable	I do not Understand

Comments

Does your SC call you back in a timely manner?

Yes	No	Not Applicable	I do not Understand

Comments

Does your SC treat you with respect?

Yes	No	Not Applicable	I do not Understand

Comments

Does your SC arrive on time for scheduled visits?

Yes	No	Not Applicable	I do not Understand

Comments

Does your SC dress professionally?

Yes	No	Not Applicable	I do not Understand

Comments

Does your SC provide you with copies of all documentation?

Yes	No	Not Applicable	I do not Understand

Comments

Does your SC explain all documentation to you?

Yes	No	Not Applicable	I do not Understand

Comments

Does your SC explain the assessment and/or re-assement process to you?

Yes	No	Not Applicable	I do not Understand

Comments

Do you know that you can always switch PAS and/or Service Coordination agencies?

Yes	No	Not Applicable	I do not Understand

Comments

Do you know who to call when you have a problem?

Yes	No	Not Applicable	I do not Understand

Comments

Do you know how to report abuse, neglect, and/or exploitation?

Yes	No	Not Applicable	I do not Understand

Comments

Do you know how to complete and submit a grievance?

Yes	No	Not Applicable	I do not Understand

Comments

Would you recommend Advocate Centered Services, Inc. to others?

Yes	No	Not Applicable	I do not Understand

Comments

Overall, are you satisfied with your current PAS agency?

Yes	No	Not Applicable	I do not Understand

Comments

Does your PAS agency communicate to you effectively?

Yes	No	Not Applicable	I do not Understand

Comments

Does your PAS agency treat you with respect?

Yes	No	Not Applicable	I do not Understand

Comments

Is your PAS agency covering all your hours?

Yes	No	Not Applicable	I do not Understand

Comments

Does your PAS agency provide you with a schedule of when each care worker will be in your home?

Yes	No	Not Applicable	I do not Understand

Comments

Do your care workers complete their daily tasks to keep you in your home?

Yes	No	Not Applicable	I do not Understand

Comments

Do you have a Back-Up Plan when your services are not able to be covered?

Yes	No	Not Applicable	I do not Understand

Comments

Additional Comments

Do you need any other services that have not been offered to you? If so, please explain.

Please explain anything we can do to better assist you.

Please fill out any additional comments, criticism, or praise about your SC and/or Advocate Centered Services, Inc. below.

May we use the comments you have provided in this survey for any future advertising?

Please note that last names and locations would be omitted in accordance with HIPAA regulations.

Yes

Signature