* 1. What is your age?

* 2. What is your gender?

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

* 4. What is the highest level of education you completed? (Check 1)

Please answer the following questions to the best of your knowledge.

* 5. Have you ever used the LCHC Family Planning Services?

* 6. Are you aware that we offer birth control pills and other birth control methods for low or no cost?

* 7. Are you aware that we offer FREE condoms?

* 8. Are you aware that we offer FREE STD (Sexually Transmitted Disease) screening?

* 9. What type of birth control methods have you heard of? Also note which you are interested in learning more about. (Check all that apply)

  Heard of Method Want More Information
Oral contraceptive (pills)
Depo Shot
Patch (Ortho Evra)
Vaginal Ring (NuvaRing)
IUD (Mirena/Skyla/Paraguard)
Implant (Implanon/Nexplanon)
Male Condom
Female Condom
Vasectomy "snip-snip"
Tubal Ligation "tubes tied"
Hysterectomy (removal of womb)
Abstinence (no sex)

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