MY INDIVIDUAL EXPERIENCE SURVEY - ADULT DAY HEALTH

With NC DHHS Home and Community Based Settings (HCBS)

Section I: About you and your service

My Street Address
I have a guardian.
I have a power of attorney.
I am my own guardian.
I do not know if I have a guardian.

Section II: General Questions


No
Job
Money
Medicine
 

Signature Page

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If you have feedback or questions, please email: HCBSTransPlan@dhhs.nc.gov.