Your Name
Family Members Name:
E-mail Address:

Instructions:
1. Please identify the ARC service/support on which you are commenting by checking the rated service(s).
Residential Services (RS)
Riverside Enterprises (work center) (RE)
Supported Employment (SE)
Community Inclusion Project (CIP)
Brunswick Center (BC)
Service Coordination (SC)
Recreation (R)
Other (O): specify

2. Please answer the following questions using the rating scale shown. Check the answer that best describes your response and if commenting on multiple services, use the program initials as indicated above. If the question does not apply to a service you are commenting on, just leave it blank.

Questions:
1. Do you feel welcomed, listened to, and an important contributor in developing/realizing your family member’s personal goals?
Always
Most of the Time
Some of the Time
Never

Comments:
2. Does your family member have have choices about what happens in their home life or what they do during the day/night?
Always
Most of the Time
Some of the Time
Never

Comments:
 
3. Are we flexible and creative in providing the supports your son family member’s needs to achieve the things that are important to them?
Always
Most of the Time
Some of the Time
Never

Comments:
 
4. Are we providing supports and services in a timely, dependable, and caring fashion?
Always
Most of the Time
Some of the Time
Never

Comments:
 
5. Do you have an important role in evaluating whether the ARC is effective and skilled at providing necessary supports and services to your family member?
Always
Most of the Time
Some of the Time
Never

Comments:
 
6. Does your family member routinely connect to friends and places in your local community?
Always
Most of the Time
Some of the Time
Never

Comments:
 
7. Does your family member routinely do something during the day (or evening) that is enjoyable and meaningful?
Always
Most of the Time
Some of the Time
Never

Comments:
 
8. Is your family member living in a safe and comfortable home with people he/she cares about?
Always
Most of the Time
Some of the Time
Never

Comments:
 
9. Are you able to comfortable talk with someone at the ARC about things that trouble you?
Always
Most of the Time
Some of the Time
Never

Comments:
 
10. Are we able to resolve issues that you have with ARC supports and services in a timely and responsible fashion?
Always
Most of the Time
Some of the Time
Never

Comments: