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Client Satisfaction Survey
Please complete this survey to let us know how we are doing. Your responses will not effect provision of service in any way.
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* Indicates required question
Date
*
MM
/
DD
/
YYYY
County of Residence
*
Choose
Brazos
Burleson
Grimes
Leon
Madison
Robertson
Washington
Which ADRC staff member assisted you? (Choose one or more)
*
Maria Molina
Jordan Scamardo
Not sure
Required
What type of service did you receive from the ADRC?
*
Information, Referral, and General Assistance
Housing Navigation
Long-Term Options Counseling
Medicare Benefits Counseling
Guidance for State funded programs
Application Assistance
Other:
Required
Did the ADRC program meet your needs?
*
Yes
No
Other:
Were any questions you had left unanswered?
*
Yes
No
If yes, please tell us what questions you still have:
Your answer
Would you recommend our program to a friend?
*
Yes
No
Were you satisfied with the assistance you received?
*
Yes
No
If no, please tell us what we could do better:
Your answer
Have the services provided helped you to regain your independence?
*
Yes
No
Does Not Apply
Do you feel the services you were provided were specific to your needs?
*
Yes
No
Other:
Were staff able to assist you in obtaining the information in a timely manner?
*
Yes
No
Was ADRC staff courteous, professional, and helpful?
*
Yes
No
Other:
Would you return to the ADRC for assistance in the future?
*
Yes
No
Maybe
Additional comments:
Your answer
If you would like the ADRC staff to follow up regarding your responses to this survey, please add your contact information below:
Your answer
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