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How do I communicate whether I am satisfied or not satisfied with the direct support worker?  Who do I call?  When would they get back to me?

How do you know if someone comes in when they are scheduled to do so?  Who checks that services are provided?  Do you expect me to sign that they have come and done the work satisfactorily?

What happens if my worker can’t come to support me?  Will you call me ahead of time?  Will you send another person to take his/her place?  What do you do so that the substitute person is familiar with me?

What are your hours of operation?  Do you have services on the weekends?  What time does the program begin and end each day?

If I have an emergency, will you be able to help me?

May I see your program? (Talk to the program staff and participants about the program activities.)

Can I drop in to see your program any time?

Where are you located?  Do you have a program near me?  (Give them your address.)

Whom do I call to set up an appointment for a visit?  

How will you communicate with my case manager and me?

You can use this space to write down questions that are important to you and relate to your needs.

Question One:__________________________________________

Question Two:__________________________________________

Question Three:__________________________________________

Question Four:__________________________________________

Service Provider Authorization Form (SPAF)

Page 40 of 43

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