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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 is helpful and listens to my concerns.

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

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* 5. Treatment/counseling is focused on achieving my goals and fits my needs.

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* 6. The care provider explains things in a way I understand.

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

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* 8. The office staff answer my questions and help if there is a problem.

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

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* 10. Who sent you here for services?

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* 11. Optional:  Name of Care Provider

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* 12. Optional: Comments and feedback

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* 13. What is your age?

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* 14. What is your gender identification?

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* 15. Which race/ethnicity best describes you?

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* 16. The waiting room is comfortable and neat.

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* 17. I feel safe when I am in or around the building.

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* 18. Name - optional:

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

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