* = Required Information

Patient Name * Date *
We were privileged to participate in the care of the above client. We are interested in rendering quality care to our clients and would appreciate your input by answering the following questions. Your evaluation will allow us to be more responsive to future client/family needs.  
1. What services(s) did you receive from the Agency?
Nursing Physical Therapy
Occupational Therapy Speech Therapy
Home Health Aide Medical Social Worker
2. Were you satisfied with the care you received?
YesNo If not, why?
3. Did you participate in your plan of care?
YesNo
4. Did you receive and understand your "Bill of Rights" including the toll free "Hotline" number that you could call if any problems were not resolved by the Agency?
YesNo
5. Did the staff visit as frequently as they stated they would when they started your services?
YesNo
6. Did you feel comfortable asking staff questions regarding your health?
YesNo
7. Did the staff person visit at a mutually agreeable time?
YesNo
8. If you had therapy, were exercise instructions given to you in a clear, written manner that you could easily understand?
YesNo
9. Did you feel that you were discharged appropriately?
YesNo
10.Would you use the services of the Agency in the future?
YesNo
Suggestions for improvement