1) The Concerns that brought me to ILCKC were adequately addressed by the ILCK staff.
Choose One
o\tStrongly agree
o\tTend to agree
o\tTend to disagree
o\tStrongly disagree
2) What type of services did you receive from ILCKC (Please place an X in all that apply)
Information/Referral
Assistive devices/equipment
Housing Services
Mobility Training
Personal Assistance Services
Transportation Services
Vocational Services
Americans with Disablities Act technical assistance
Advocacy
Independent Living Skills/Life Skills Training
Benefits Counseling
Peer Counseling or Support
Recreation
Youth Transition Services
Other: Please Specify
3) After making your first request for services, to what degree were you included in the development of your Independent Living Plan or setting goals and outcomes or objectives?
Choose One
o\tInformation/referral
o\tAssistive devices/equipment
o\tHousing services
o\tMobility training
o\tPersonal assistance services
o\tTransportation services
o\tVocational services
o\tAmericans with Disabilities Act technical assistance
o\tAdvocacy
o\tIndependent Living skills/life skills training
o\tBenefits counseling
o\tPeer counseling or support
o\tRecreation
o\tYouth transition services
o\tOther: Please specify
4) Were services and informational material you received presented to you in an accessible, understandable manner?
Choose One
Yes
No
5) Have you benefited from the services you received?
Choose One
Yes
No
6) Overall, how would you describe the services you received?
Choose One
o\tExcellent
o\tGood
o\tModerate/Fair
o\tPoor
7) Are there any services that would improve your independence that are not available in your community?
Please List:
8) What is the name of the community where you live?
Optional Information about me:
1) I am:
Choose One
o\tA person with a disability who has received ILCKC services
o\tA family member of a person w/a disability who has received ILCKC services
o\tA staff member of a community agency that works with ILCKC staff
2) I consider myself to be a part of a minority group in the community.
Choose One
Yes
No
Name of Group or Ethnicity
Other Comments you would like to make:
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