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Client Satisfaction Survey
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Client Satisfaction Survey
Posted on
July 6, 2021
by
Ability Homecare
Care Recipient Name
(Required)
First
Last
Did the staff member who came to your home provide our office and cell phone numbers so you can reach us anytime, even after hours?
(Required)
Yes
No
Have you had to use either number?
(Required)
Yes
No
Comments
Did our staff explain our complaint resolution process to you?
(Required)
Yes
No
Comments
Is/was the caregiver on time for their scheduled shift?
(Required)
Yes
No
Did he/she complete tasks outlined in the care plan or what you needed them to do to your satisfaction?
(Required)
Yes
No
Comments
Overall are/were you pleased with the caregiver’s performance (quality of care provided, professionalism, and attitude) in rendering care to you and/or your loved one?
(Required)
Yes
No
Comments
Do you feel that you and/or your family have been/was treated with respect and dignity by our staff/caregiver?
(Required)
Yes
No
Comments
Was/is your billing information accurate and invoiced timely?
(Required)
Yes
No
Comments
If you have comments regarding our home health services, staff/caregiver, please write your comments in the space below.
Your overall satisfaction with our agency, home care services, professionalism, ease with changing your schedule, addressing complaints, etc.?
(Required)
Would you recommend Ability Homecare to your family and friends?
(Required)
Yes
No
If no, will you please explain why not?
(Required)
If you are/were pleased with our services we ask that you write a client testimonial which will be used in our advertising campaign including but not limited to print, radio, television, Web site, etc.
In an effort to protect your privacy please tell us how you would like for your name to be displayed:
First and last name
First name only
Last name only
Comments
Your Name
(Required)
First
Last
Signature
(Required)
Today's Date
(Required)
MM slash DD slash YYYY
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