Section I: About you and your service

Local Lead Agency *
Provider Name *
Provider Address *
Provider City *
State *	North Carolina Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Provider Zip Code *
Guardianship *	I have a guardian. I have a Limited Guardian (might be for decisions about healthcare, legal issues, money, or other) I am my own guardian. I do not know if I have a guardian.

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Section II: General Questions

1. I don't have a job, but I have a place(s) to go during the day.	Yes	No	Don't Know	Doesn't Apply
2. If I want to, I can have a job.	Yes	No	Don't Know	Doesn't Apply

3. I go places like the bank, the grocery store, the mall, restaurants and the place where I go pray.	Yes	No	Don't Know	Doesn't Apply
4. I do things I want to do.	Yes	No	Don't Know	Doesn't Apply
5. I do things with others who live in my town.	Yes	No	Don't Know	Doesn't Apply
6. I have support to do the things I want to do in my community at the times I want to do them.	Yes	No	Don't Know	Doesn't Apply

7. I use my money the way I want.	Yes	No	Don't Know	Doesn't Apply
8. I can get my money when I need it.	Yes	No	Don't Know	Doesn't Apply
9. I have a phone I can use to call friends and family.	Yes	No	Don't Know	Doesn't Apply
10. I have any support I need to keep my assistive technology, phone and/or computer working well.	Yes	No	Don't Know	Doesn't Apply
11. I can use my books, phone, games, etc., when I want to.	Yes	No	Don't Know	Doesn't Apply
12. I can be alone if I want to be.	Yes	No	Don't Know	Doesn't Apply
13. My friends and I can be alone when we want to be.	Yes	No	Don't Know	Doesn't Apply
14. I am treated the way that I want to be.	Yes	No	Don't Know	Doesn't Apply
15. I feel safe around the staff that work with me.	Yes	No	Don't Know	Doesn't Apply

16. I take medicine that helps me control the way I act around others.	Yes	No	Don't Know	Doesn't Apply
17. I (or my guardian) talked with my doctor and gave the doctor an "okay" for me to take medicine for behavior.	Yes	No	Don't Know	Doesn't Apply
18. My medicine helps me to feel better.	Yes	No	Don't Know	Doesn't Apply

19. I choose my own services.	Yes	No	Don't Know	Doesn't Apply
20. I get to pick the provider I want for my services/supports.	Yes	No	Don't Know	Doesn't Apply
21. I pick the staff that helps me do things.	Yes	No	Don't Know	Doesn't Apply
22. I can get help, if I need it, to make decisions about my rights.	Yes	No	Don't Know	Doesn't Apply
23. I have say-so and control over my life.	Yes	No	Don't Know	Doesn't Apply
24. I choose what I do with my free time.	Yes	No	Don't Know	Doesn't Apply
25. I choose the staff who help me to do what I want in my free time.	Yes	No	Don't Know	Doesn't Apply
26. I can get food whenever I want it.	Yes	No	Don't Know	Doesn't Apply
27. I can have people visit me whenever I want.	Yes	No	Don't Know	Doesn't Apply
28. I am able to get around easily at my work or where I spend my day.	Yes	No	Don't Know	Doesn't Apply
29. Please share with us anything else you want to tell us about the services you get: Do not enter your name, Medicaid number, phone number or address.

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Signature Page

Someone helped me fill out this survey. *	Yes	No
The person who helped me with this survey is: *	-- Select One -- I filled this out by myself Legal Guardian/POA Staff Member Friend Family Member (but not my guardian) Community Guide Care Coordinator
If you were asked to fill out the survey, please provide the survey number you were given.
If you would like to be contacted by your LME-MCO or LLA, please click this here.
Date