* = Required Information
1. Overall, please rate your satisfaction with UniqueHab Solutions:
Always
Usually
Sometimes
Never
Comments
2. UniqueHab staff provide me with the information I need:
Always
Usually
Sometimes
Never
Comments
3. Are staff in your home when you need them?
Always
Usually
Sometimes
Never
Comments
4. Do you like the people that work in your home?
Always
Usually
Sometimes
Never
Comments
5. Do they know how to help you?
Always
Usually
Sometimes
Never
Comments
6. Do you feel it is easy to access your services?
Always
Usually
Sometimes
Never
Comments
7. Do you feel that staff respect your personal property?
Always
Usually
Sometimes
Never
Comments
8. When calling the office, office staff were courteous.
Always
Usually
Sometimes
Never
Comments
9. If you left a message for office staff, your call was returned promptly.
Always
Usually
Sometimes
Never
Comments
10. When calling the on-call phone after hours or on weekends, your call was answered, or was returned within 30 minutes.
Always
Usually
Sometimes
Never
Comments
11. Do you feel your current services meet your needs?
Always
Usually
Sometimes
Never
Comments
12. Are there services you feel you could benefit from that you are not currently receiving?
Always
Usually
Sometimes
Never
Comments
Please tell us how we have exceeded your expectations or have fallen short:
Action Plan:
Staff_Name:
Date:
Submit