Consumer Satisfaction Survey Service Review Period Reviewed By (OFFICE USE ONLY) Corrective Action Plan Necessary? (OFFICE USE ONLY) Yes No Consumer Name(required) Person Completing Survey Name(required) Relationship to Consumer(required) Waiver(required) Consolidated Person Family Driven Autism 1) Were you provided the services outlined in your ISP at the frequency and duration noted?(required) Yes No If no, explain: 2) Did you participate in developing the goals and objectives in your ISP?(required) Yes No If no, explain: 3) Are you satisfied with the quality of the services being provided to you?(required) Yes No If no, explain: 4) Do you have access to all of the information about you, your ISP, your services or other information about the agency?(required) Yes No If no, explain: 5) Have grievance procedures been explained to you so you know what to do if you are not satisfied with your services or with any action of the agency?(required) Yes No If no, explain: 6) Have you ever filed a complaint/grievance?(required) Yes No If yes, explain: 7) If you ever filed a complaint/grievance were you satisfied with how were you treated?(required) Yes No If no, explain: 8) If you have ever filed a complaint/grievance were you satisfied with the result?(required) Yes No If no, explain: 9) Are you able to make choices during services?(required) Yes No If no, explain: Signature of Reviewer(required) Date(required) Please note any additional comments or suggestions here: