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* 1. This is a confidential and private place.

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* 2. I am satisfied with the amount of time it took to access services.

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* 3. The care provider was helpful and listened to my concerns.

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* 4. I was treated with respect by all staff.

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* 5. Who sent you here for services?

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* 6. Optional:  Name of Care Provider

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* 7. Optional:  Comments and feedback

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* 8. What is your age?

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* 9. What is your gender identification?

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* 10. Which race/ethnicity best describes you?

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* 11. Name - optional

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* 12. The waiting room was comfortable and neat.

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* 13. I felt safe when in or around the building.

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* 14. My appointment today was in the following office:

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