Form Center

2. 
3. Thank you for taking the time to tell us about your contact with the Kenosha County Aging and Disability Resource Center (ADRC). Your feedback is so meaningful to us. The more information you provide, the better we can understand your experience. You may also call us at 262-605-6646 or email at [email protected]
5. How would you best describe yourself?

   Select one best answer:

   1. Older person (age 60+)
   2. Person with a disability (age 18 - 59)
   3. Caregiver of an older person or person with a disability
   4. Family or friend of an older person or person with a disability
   5. Professional
   6. Other
6. What was your reason for contacting the Aging and Disability Resource Center?
8. How did you contact the ADRC?

   Check all that apply:

   1. Telephone
   2. In person - at the ADRC Office
   3. In person - at my home
   4. In person - somewhere else
   5. Email
   6. Other
9. What kind of help did you receive?

   Check all that apply:

   1. Information
   2. Referral for a service
   3. Options Counseling
   4. Eligibility and enrollment for the Medicaid Long Term Care Programs (Family Care, IRIS, Partnership)
   5. Benefits Counseling
   6. Dementia Care Services
   7. Adult Protective Services
   8. Caregiver Support
   9. Health and Wellness Classes
   10. Other
11. Were you treated with respect?

    Select one best answer:

    1. Yes
    2. Somewhat
    3. No
12. How well did the services you received meet your need?

    Select one best answer:

    1. Very well
    2. Well
    3. Not well
14. How satisfied are you with the amount of help you received?

    Select one best answer:

    1. Very Satisfied
    2. Satisfied
    3. Not Satisfied
15. How confident are you about the information you received?

    Select one best answer:

    1. Very Confident
    2. Confident
    3. Not Confident
17. How would you rate the overall quality of your experience with the ADRC?

    Select one best answer:

    1. Excellent
    2. Good
    3. Poor
19. Is there anything that would have been more helpful to you?
20. General Comments
22. Would you like to be contacted by the ADRC about your experience ?

    Select one:

    1. Yes
    2. No
23. If yes, please provide your name and phone or email:
25. Thank you!
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

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