First Name:

Last Name:

Phone Number:

Email Address:

1. Are you satisfied with your job search?: Yes No

2. Did we encourage you to actively participate in your job search?: Yes No

3. Do you like where you work?: Yes No

4. Can you get to work in a reasonable amount of time?: Yes No

5. Are you learning to advocate for yourself and make your own decision?: Yes No

6. Are you happy with the services you are receiving?: Yes No

7. Do you feel involved with the development of you plan for services?: Yes No

8. Do you need an appointment with your consumer services advocate?: Yes No