Christian Horizons Family Survey 2011

Quality of Service Questionnaire

Thank you for taking a few minutes to complete this questionnaire. Please have this form completed by September 30, 2011. The purpose of this survey is to gain feedback on Christian Horizons' supports and services for family members and advocates. The information you provide will be kept confidential.

If you have any questions or concerns, or are having technical difficulties with this survey, please contact Megan Macdonald at or 519-650-0966 ext. 3144



Please answer the following questions by clicking the corresponding circle that most closely indicates your opinion based on the following rating:


Strongly Disagree



Strongly Agree

Not applicable

1. Your family member has opportunities for personal growth based on his/her interests, dreams, and goals.


2. Your family member has personal friends in the community.


3. Staff provide personal care that is appropriate for your family member (e.g., dressing, hygiene, etc.).


4. Your family member's medical needs are being met (i.e., appropriate medications are being administered safely, appropriate medical supports are provided).


5. Your family member receives appropriate support to promote his/her emotional well-being (e.g., daily encouragement, formal counseling/therapy as required).


6. Your family member's home environment is safe.


7. Your family member receives the appropriate level of supervision and support or has been taught the appropriate safety skills to move about at home and in the community safely (i.e., whether independent or requiring assistance).                                                                                                   

Strongly Disagree



Strongly Agree

Not applicable

8. Your family member is treated with dignity and respect.


9. Your family member's personal space, personal possessions and privacy are respected (e.g., is able to be alone with guests when needed, mail is opened by staff only when it is okay with your family member).


10. Your family member is able to communicate freely with friends and family.


11. Your family member eats a well-balanced diet.


12. Your family member regularly participates in physical fitness activities that promote his/her health and well-being.


13. Your family member is encouraged to grow and develop in his/her spiritual life (e.g., devotions, sharing, prayer, worship).


14. Your family member's spending reflects what is important to him/her.



Strongly Disagree



Strongly Agree

Not applicable

15. You are confident that your family member's finances are being managed appropriately.


16. Your family member is satisfied with current daytime activities (i.e., they experience fulfillment from participating in their current day activities).


17. When you visit the program, it is usually:          
          a) Clean                                                                                                  
          b) Comfortable atmosphere/environment


 Comments related to Questions 1 to 17 on Service Provided:



Strongly Disagree



Strongly Agree

Not applicable

18. Staff are genuinely interested in your family member.


19. Staff support your family member with competence and professionalism.


20. You experience open and timely communication with staff (e.g., you are contacted regarding significant changes, serious occurrences).


21. You are invited to attend planning conferences for your family member at least annually.                                                                                                    
22. Staff ask for your input regarding care issues related to your family member.


23. You are welcome to be personally involved in your family member's life.


24. You know who to ask if you have questions about service and support issues.


25. You know the complaints process if you have further concerns that cannot be addressed or are not being addressed by staff at the program.


 Comments relating to questions 18-25 on Interactions with Christian Horizons:


26. Overall, how would you rate the services provided?


   Poor                                                                Excellent



27. I am pleased with the following areas:


28. I am concerned with the following areas:



29. What is your relationship to the person who receives supports from Christian Horizons?



Other relative (please specify):

Advocate (please specify role):

Other (please specify):

30. Approximately how long has your family member received services from Christian Horizons?

  More than 10 years

5 - 10 years

2 - 5 years

Less than 2 years

31. What type of supports does your family member currently receive from Christian Horizons? (please check all that apply)

Community Residence (24 hour residential)

Supported Independent living

Community Participation Supports/ Day Activities

Family Home


Other (please describe):

32. In which district does your family member currently  receive supports from Christian Horizons?

  Central (e.g., Durham, Toronto)

Central East (e.g., Cobourg, Peterborough, Lindsay)

East (e.g., Ottawa, Kingston)

North (e.g., Algoma, Sudbury, Almaguin, Muskoka, Orillia, Simcoe, York)

South (e.g., Oxford, Elgin, London, Essex, Chatham-Kent, Lambton)

West (e.g., Halton, Peel, Hamilton, Niagara, Waterloo, Wellington)