Collection Information

This survey is being conducted to gather consumer input for the developing Coordinated Intake system. This version is intended for input gathered in 1-1 interview situations.

The first page gathers information about the setting in which the input is gathered. The second and third pages include all questions discussed in two-part consumer focus groups. Thank you very much for your assistance!

* 1. Agency/Site of Interview

* 2. Date of Interview

Date:
/
/

* 3. Staff Name

* 4. Staff Contact Information

* 5. What is the age of the person interviewed?

6. What is the gender of the person being interviewed?

7. What is the current housing situation of the person being interviewed?

T