1. What services do you receive? (Check all that apply:)
Berkeley Industries
Early Intervention
Residential
Respite
Service Coordination
Other: 

2. Who is completing this form?
Person receiving services
Parent or Guardian of person receiving services

3. Are you getting the services and supports you need? 
Yes         Sometimes         No

4. Are you pleased with the services you are receiving? 
Yes         Sometimes         No

5. Did you have the opportunity to decide who would provide the services? 
Yes         Sometimes         No

6. Does your annual plan have what you want in it? 
Yes         Sometimes         No

7. Are staff respectful and polite to you? 
Yes         Sometimes         No

8. Do staff listen to your problems and offer to help? 
Yes         Sometimes         No

9. Are all your questions answered promptly? 
Yes         Sometimes         No

10. Do you know who to call if you have concerns or questions? 
Yes         Sometimes         No

12. Is there anything else you want to tell us?


If you want us to contact you for further information or clarification, please complete the boxes below:

Name: 

Phone Number: 
(area code) -  - 

E-mail Address (optional):