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* 1. This exit form is being completed by the:

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* 2. Name Of Centre:

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* 3. Location :

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* 4. Current Marital Status:

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* 5.  Date of last visit/exchange while in the program

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* 6. Termination of services requested by:

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* 7. Reason for program termination:

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* 8. New access arrangements made:

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* 9. Satisfaction of party with: Hours of Service

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* 10. Satisfaction of party with: Facilities and Equipment

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* 11. Satisfaction of party with: Neutrality of service         

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* 12. Satisfaction of party with: Safety of the Environment for the Child

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* 13. Satisfaction of party with: Safety of the Environment for Self

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* 14. Satisfaction of party with: Restriction of visits to the site of the program

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* 15. Satisfaction of party with: Cost of service (if applicable)

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* 16. Satisfaction of party with: Staff

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* 17. Satisfaction of party with: Distance to program

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* 18. Satisfaction of party with: Provision of reports describing visits

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* 19. Satisfaction of party with: Visiting in a group setting

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* 20. Satisfaction with the supervision of visits : were the visits (please check one):

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* 21. What other services (relevant to access) have you accessed in the past or are you using now? what other services would you like to use for yourself/ your children?

  Past/Present     Future
Group counselling                                           
Individual counselling                                     
Dispute mediation                                           
Family therapy                                                 
Parenting classes
Assessment
Legal and clinical services
Support Group  

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* 22. Please write down any other comments you have regarding the Supervised Access Program:

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