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* 1. What is your name? (You are not required to answer this and can submit your feedback without a name.)

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* 2. Is there a counselor or staff member you would like to recognize for their work? No detail is too small to share!

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* 3. How has your life been touched by Samaritan Counseling Center, either in small ways or big ways?

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* 4. By submitting your story, you consent to Samaritan Counseling Center sharing your story for promotional materials. We respect your privacy, so please indicate your preference.

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