Today's Date

MM

DD

YYYY

What Sunnyhill service do you receive? *

ALF

ISLA

Pre-ISLA

Waiver

1. I am satisfied with quality of services provided by the staff:

Yes

No

2. My staff treats me with respect and courtesy:

Yes

No

3. My staff listens to my needs:

Yes

No

4. My staff asks me for my ideas and choices when planning activities:

Yes

No

5. I have the opportunity to choose my goals:

Yes

No

6. My staff assist me with achieving my goals:

Yes

No

7. My staff respects my rights as an individual and keeps information confidential:

Yes

No

8. My staff ensure that I arrive for all my appointments and activities on time:

Yes

No

9. My staff encourages me to make my own choices regarding my health and well-being:

Yes

No

10. My staff listens carefully to my concerns and seems to understand me:

Yes

No

11. My staff has a positive attitude:

Yes

No

12. My staff helps me learn how to take care of myself and be more independent:

Yes

No

13. My staff helps me solve my problems or concerns:

Yes

No

14. I know how to contact Sunnyhill Administrators:

Yes

No

Do you participate in additional support programs.

Adventures Camp

Adventures Mini Camp

Adventures Travel

Art Programs

Day Programming

Employment

Music Programs

Transportation Programs

Workshop

Person Supported Contact Name

If you would like to be contacted by Sunnyhill, please provide your name.

First Name

Last Name

Guardian Contact Name

First Name

Last Name

Phone

(###)

###

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