2023 Satisfaction Survey (Families/Caregivers)

2022 Satisfaction Survey

For Families and Caregivers - Please complete by February 15, 2023
This form is HIPPA Compliant. All information is confidential.
Who is filling out this form?*

Family MemberSiblingOther Family MemberOther Caregiver
What services does The Arc Westchester provide for your family member:*

Early Intervention/PreschoolDay ProgramsTransition ServicesEmployment ServicesRecreation/RespiteResidentialSelf-DirectionClinic-Wellness CenterOther

Please rate any of the services your family member receives:*

The Arc Westchester:*

	Strongly Agree	Agree	Disagree	Stronly Disagree
Keeps me informed
Help people feel safe
Provides a comfortable environment
Encourages my involvement
Promotes health and wellness
Cultivates healthy relationships
Supports lifelong learning
Fosters independence
Staff are supportive and respectful
Staff respond to my concerns

Please share any comments about specific programs.
We are updating our records. Please fill in the information below by February 15. You will be entered into a raffle to receive a small framed piece of art from our gallery265. Thank you!
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
If you have any questions please contact Lolli Ross at 914.495.4589 or email lross@arcwestchester.org. Thank you for your feedback!
Should be Empty:

2022 Satisfaction Survey