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CIL Satisfaction Survey
A problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator.
Which service were you provided with?
Please Select
Assistive Technology
Disability Benefits Information
Emergency Preparedness
Employment Services
Housing
Information and Referral
Living Well with a Disability Group
Medical Advocacy
Nursing Home Transition Assistance
Peer Counseling
Personal Attendant Services Information
Residential Access (e.g., ramps, safety bars, lifts, other home modifications)
Transportation/Travel Training
Youth Programs
Other
If Other, please specify
Which staff member assisted you last?
Please Select
Unknown
Adelene Miranda
Adriana Zaldivar
Alexander Sing
Ash Alunan
Ash Wagner
Britney Salas
Camiel Hayes
Cara Bondurant
Carly Gibbs
Ciara Lovelace
Emma Martin
Fox Machado
Henry Maeko
Jade Theriault
Jillian Gibbons
John Benson
Jorge Lara Castillo
Julia Newton
Karla Salazar-Macedo
Laurence Carew
Lucky Maxwell
Max Dolane
Morgan Kanninen
Robin Earth
Ryan Houldin
Sheela Gunn
Stacy Brown
Theancy Galland
Tiffini Hickerson
The service(s) I received were accessible.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
The service(s) I received matched my expectations.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
The person(s) who assisted me was respectful and kind.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
The person(s) who assisted me answered my questions helpfully.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am better able to take care of myself, after the service(s) I received.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am better able to access my home and/or community, after the service(s) I received.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am more knowledgeable about community services available to me, after the service(s) I received.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I would refer others to the CIL.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Do you have any additional comments or questions? Please share them with us.
Would you like to include any personal demographic information? All fields are optional, and this information will remain confidential.
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Gender
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What is your annual household income?
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15,000 – 24,999
25,000 – 34,999
35,000 – 49,999
50,000 – 74,999
75,000 – 99,999
100,000 – 149,999
150,000 and Over
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