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* 1. What program are you receiving services in?

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* 2. This is a confidential and private place.

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

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* 4. I felt comfortable sharing treatment concerns with my care provider.

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* 5. Treatment/counseling was focused on achieving my goals and fit my needs.

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* 6. The care provider explained things in a way I understood.

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

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* 8. The office staff answered my questions and helped if there was a problem.

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* 9. Did you and your care provider develop a discharge/continuing care plan (what 
you will do after you leave)?

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* 10. Did staff connect you with primary health care services (medical doctor)?

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* 11. Were you given referrals for additional services, if needed?

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* 12. Would you recommend our agency to friends and family?

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* 13. Who sent you here for services?

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* 14. Optional:  Name of Care Provider

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* 15. Optional:  Comments and feedback

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* 16. What is your age?

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* 17. What is your gender identification?

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* 18. Which race/ethnicity best describes you?

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* 19. Optional:  Name

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* 20. the waiting room was comfortable and neat.

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* 21. I felt safe in and around the building.

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

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