El Mirador Inc. Client Satisfaction Survey

We would like to hear all about your experience with our company. Please take a moment to think about the services you receive from El Mirador Inc., our supervisors, our caregivers and even the people you have had contact over the phone at El Mirador Inc.

1. How long have you been receiving our services? ( Please check one ) Required Question

	0-3 Months
	3-6 Months
	6-12 Months
	1-2 Years

2. Services received from El Mirador Inc? Required Question

SELECT THE NUMBER THAT CORRESPONDS WITH YOUR EVALUATION

3. WHEN YOU HAD CONTACT WITH US IN PERSON OR OVER THE TELEPHONE,
Were your questions and concerns answered adequately? Required Question

4. Did we listen, show interest and genuine concern for you? Required Question

5. Were your telephone calls answered promptly? Required Question

6. WHEN OUR CAREGIVER WAS IN YOUR HOME
Were you treated with compassion and concern? Required Question

7. Were your needs met to your satisfaction? Required Question

8. Was our caregiver prompt and dependable? Required Question

9. Did you feel secure and confident in our ability to care for you? Required Question

10. WHEN YOU STARTED SERVICES
Where you able to contact the appropriate person on the phone? Required Question

11. Were your services clearly and fully explained? Required Question

12. Was your plan of care clear and easy to understand? Required Question

13. Were our Supervisors and Office staff members courteous and helpful? Required Question

14. Do you understand your Consumer's rights and responsibilities for the services that you receive? Required Question

	Yes
	No

15. Are you ever asked or have you ever requested to participate in care/family conferences or other meetings regarding your services? Required Question

	Yes
	No

16. HOW WOULD YOU RATE OUR SERVICES OVERALL? Required Question

17. Please write any comments or concerns:

18. Name (Optional)

19. Date MM/DD/YY Required Question

	Case Management
	D&E Homemaker Services
	Environmental Modifications
	PCO Services (Directed)
	PCO Services (Delegated)
	Other

Always	Usually	Sometimes	Rarely	N/A

Always	Usually	Sometimes	Rarely	N/A

Always	Usually	Sometimes	Rarely	N/A

Always	Usually	Sometimes	Rarely	N/A

Excellent	Very Good	Good	Not so Good	Bad