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* 1. First Name

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* 2. Last name

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* 3. Are you a:

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* 4. How long have you been connected to or received care from HOPES?

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* 5. How did you first hear about HOPES?

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* 6. What is your favorite memory of HOPES and/or favorite memory with a HOPES staff member?

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* 7. Answer the question, if HOPES didn’t exist…

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* 8. Are you willing to share your HOPES story with a staff member? If so, please provide your contact information (Phone number and\or Email):

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* 9. If you would like to stay up-to-date on HOPES’ services and impact, sign up for our newsletter by adding your email below:

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