[contact-form to=’info@paalprogram.org’ subject=’Consumer Satisfaction Survey Response’][contact-field label=’Consumer Name’ type=’name’ required=’1’/][contact-field label=’Person Completing Survey Name’ type=’name’ required=’1’/][contact-field label=’Relationship to Consumer’ type=’text’ required=’1’/][contact-field label=’Waiver’ type=’radio’ required=’1′ options=’Consolidated,Person Family Driven,Autism’/][contact-field label=’1) Were you provided the services outlined in your ISP at the frequency and duration noted?’ type=’radio’ required=’1′ options=’Yes,No’/][contact-field label=’If no%26#x002c; explain:’ type=’textarea’/][contact-field label=’2) Did you participate in developing the goals and objectives in your ISP?’ type=’radio’ required=’1′ options=’Yes,No’/][contact-field label=’If no%26#x002c; explain:’ type=’textarea’/][contact-field label=’3) Are you satisfied with the quality of the services being provided to you?’ type=’radio’ required=’1′ options=’Yes,No’/][contact-field label=’If no%26#x002c; explain:’ type=’textarea’/][contact-field label=’4) Do you have access to all of the information about you%26#x002c; your ISP%26#x002c; your services or other information about the agency?’ type=’radio’ required=’1′ options=’Yes,No’/][contact-field label=’If no%26#x002c; explain:’ type=’textarea’/][contact-field label=’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?’ type=’radio’ required=’1′ options=’Yes,No’/][contact-field label=’If no%26#x002c; explain:’ type=’textarea’/][contact-field label=’6) Have you ever filed a complaint/grievance?’ type=’radio’ required=’1′ options=’Yes,No’/][contact-field label=’If yes%26#x002c; explain:’ type=’textarea’/][contact-field label=’7) If you ever filed a complaint/grievance were you satisfied with how were you treated?’ type=’radio’ required=’1′ options=’Yes,No’/][contact-field label=’If no%26#x002c; explain:’ type=’textarea’/][contact-field label=’8) If you have ever filed a complaint/grievance were you satisfied with the result?’ type=’radio’ required=’1′ options=’Yes,No’/][contact-field label=’If no%26#x002c; explain:’ type=’textarea’/][contact-field label=’9) Are you able to make choices during services?’ type=’radio’ required=’1′ options=’Yes,No’/][contact-field label=’If no%26#x002c; explain:’ type=’textarea’/][contact-field label=’Signature of Reviewer’ type=’name’ required=’1’/][contact-field label=’Date’ type=’text’ required=’1’/][contact-field label=’Please note any additional comments or suggestions here:’ type=’textarea’/][/contact-form]