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Client Regional Center Survey
(1 = Strongly Disagree 10 = Strongly Agree)
1. If you have been, or are the caretaker of a child or adult who has been assessed by a Regional Center, what is the name of your Regional Center?
2. On a scale of 1-10, with 10 being the highest, how satisfied are you with the assessment process?
1
2
3
4
5
6
7
8
9
10
3. How long did it take to schedule an appointment for the assessment of diagnosis?
1-2 Weeks
3-4 Weeks
5-6 Weeks
Longer
4. On a scale of 1-10, with 10 being the highest, how informed did you feel about the services available through the Regional Center following the initial assessment?
1
2
3
4
5
6
7
8
9
10
5. Did you receive an information guide about the services or resources offered by your Regional Center during the initial assessment?
Yes
No
6. Have you been provided with an Individualized Program Plan (IPP)?
Yes
No
7. On a scale of 1 -10, with 10 being the highest, how satisfied are you with the IPP?
1
2
3
4
5
6
7
8
9
10
8. On a scale of 1-10, with 10 being the highest, are you, or is the individual you care for, improving/progressing with the IPP?
1
2
3
4
5
6
7
8
9
10
9. Have you been denied any services?
Yes
No
10. If so, which service(s)?
11. How often do you speak with your caseworker?
Weekly
Monthly
Bi-Monthly
Annually
12. On a scale of 1-10, with 10 being the highest, how satisfied are you with your caseworker?
1
2
3
4
5
6
7
8
9
10
13. How long does it take to receive a response to inquiries made to your caseworker?
1-2 Days
3-5 Days
1-2 Weeks
Longer
14. On a scale of 1-10, with 10 being the highest, how satisfied are you with your service provider(s)?
1
2
3
4
5
6
7
8
9
10
15. Are you currently on a wait list for services?
Yes
No
16. If so, for how long?
17. On a scale of 1-10, with 10 being the highest, how would you rate your overall satisfaction with your Regional Center?
1
2
3
4
5
6
7
8
9
10
18. Would you like to share additional information regarding your interaction with the Regional Center?
19. Would you like someone to contact you regarding your concerns? (If yes, please give us your name and contact information below.)
Yes
No
First Name
Last Name
Address 1
Address 2
City
State
Zip
Email Address
Leave this field blank
Submit
