Respite Survey

Respite Survey

The following survey is an opportunity for you to give DWIHN feedback regarding your satisfaction with Respite services and/or staff. Please note that this survey should be completed by the member receiving service or the parent/guardian of the member receiving the service as appropriate. Your CMH Therapist, Facilitator, Supports Coordinator or Case Manager can assist you as needed. This survey should not be completed by a Respite staff person or with their help/input. This survey should be completed every 6 months while receiving Respite services. This survey and any information transmitted within it are confidential and intended solely for the use of the individual or entity to whom they are addressed. This survey contains confidential information and is intended only for the intended individual. If you are not the intended individual you should not disseminate, distribute, or copy this survey or its contents.

In regard to children and youth receiving Respite, If you have any questions or concerns please contact Kim Hoga @ khoga1@dwihn.org, or Monica Hampton at mhampton@dwihn.org.

In regard to adults receiving Respite, if you have any questions or concerns please contact Marianne Lyons at mlyons@dwihn.org.

Contact Information

Contact information of person completing the form.

First & Last Name*

Phone Number*

Email Address*

Name of Respite Provider Agency*

Respite Staff Name*

Individual Completing the Survey*

Select

Individual Completing Survey - Additional Comments

Indicate Relationship*

Age*

Select

Age - Additional Comments

Member Name*

Start Date of Current Respite Staff*

How much time did it take Respite staff to begin?*

Select

Time to Begin - Additional Comments

If more than 2 weeks, what were the barriers that caused the delay in service?*

Over the past 6 months have Respite staff left?*

Select

Staff Left - Additional Comments

How often? How much of a gap in between staff?*

Does your Respite staff arrive on time for their scheduled shifts?*

Select

Staff Arrival - Additional Comments

The services I/my child receive are following the goals/objectives of my/my child's Individual Plan of Service (IPOS) as it relates to Respite.*

Select

Goals/Objectives - Additional Comments

I'm satisfied with the time it took for Respite staff to be hired and start to work with me/my child.*

Select

Staff Hired - Additional Comments

Staff are helping me/my child reach the Respite goals that I/my child have.*

Select

Goals - Additional Comments

Respite services have made a positive impact in mine or my child's life.*

Select

Impact - Additional Comments

I know who I can talk to if I am not satisfied with my Respite services.*

If you answered no, you can contact Kim Hoga at khoga1@dwihn.org or Monica Hampton at mhampton@dwihn.org or by calling 313-833-2500 and ask for Kim or Monica.

Select

Satisfaction - Additional Comments

My culture and traditions are respected by the Respite staff in my home.*

Select

Culture/Traditions Respected - Additional Comments

What barriers, if any, are present?

I have had the opportunity to educate my Respite staff on house rules, culture and tradition.*

Select

Rules/Culture/Tradition - Additional Comments

Would you be willing to share your contact information with Detroit Wayne Integrated Health Network (DWIHN)?*