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* 1. What is your ethnicity? (Please select all that apply.)

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* 2. What is your age?

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* 3. What is your gender?

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* 4. Which of the following categories best describes your employment status?

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* 5. What are your current living arrangements?

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* 6. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

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* 7. Did you get the kind of service you wanted?

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* 8. To what extent has our program met your needs?

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* 9. If a friend need similar help, would you recomment the program to him or her?

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* 10. Have the services you received helped you to deal more effectviely with your problems?

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* 11. If you were to seek help agin, would you come back to our program?

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* 12. In an overall, general sense, how satisfied are you with the services received?

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* 13. The response of staff to my phone calls.

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* 14. The extent to which the program was explained to you.

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* 15. The extent staff respected your culture or background

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* 16. The personal manner (courtesy, respect, sensitivity) of the person you saw.

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* 17. How did you find out about our agency? (Please select all that apply)

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* 18. Please check off all of the Concilio programs from which you and/or your family received services. If you participated in more than one program, check as many apply. 

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* 19. Would you like to be entered into our raffle?

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* 20. Please enter your email below.

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