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* 1. Which organization do you receive services from?

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* 2. Which service(s) are you currently receiving? (Check all that apply)

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* 3. Who is your service provider(s)?

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* 4. Is your service provider dependable?

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* 5. Are you treated with kindness and respect?

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* 6. Are the services you are receiving helpful?

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* 7. Do you receive services as often as you need?

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* 8. Are you satisfied with your service provider?

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* 9. Do you find that our environment is clean, safe & welcoming?

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* 10. Do you have any additional comments, questions, or concerns you would like to share?

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