Please choose one response that best represents your view. 

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* 1. I feel safe in the building where I receive services.

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* 2. I feel safe with the people who work at this clinic.

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* 3. Staff respect my personal space and boundaries.

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* 4. Staff treat me with respect.

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* 5. If staff tell me they will do something, they follow through.

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* 6. I trust the people who work at this clinic.

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* 7. Staff at this clinic listen to people who have experienced trauma when making decisions about how to run the clinic.

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* 8. I know that at this clinic some clients/family members are invited to participate in clinic functions, like serving on a committee or board.

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* 9. Staff have helped me connect to people with similar backgrounds or life experience to mine who can support or be a role model to me.

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* 10. If I give staff feedback about how services are working for me (or people like me), I am confident this clinic will pay attention to my feedback.

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* 11. Staff have asked me if the services I get at this clinic are helping me.

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* 12. Staff regularly ask me how satisfied or happy I am with the services I receive.

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* 13. When staff make decisions about my treatment or services they treat me like a partner and listen to what I want.

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* 14. Staff listen to me if I want to make changes to my services or treatment plan.

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* 15. I can ask staff at the clinic for what I need.

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* 16. Staff are respectful of my gender identity.

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* 17. Staff at the clinic respect my culture, traditions and beliefs.

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* 18. Staff at the clinic understand that my culture, traditions and beliefs might be different from theirs.

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* 19. I would feel safe talking with staff at this clinic about difficult or frightening experiences I may have had.

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* 20. I would recommend this clinic as a good place for anyone who has experienced violence, abuse or other trauma.

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* 21. Staff at this clinic truly want to help people who have experienced trauma. 

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* 22. Where does the patient receive services?

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* 23. Reason for being here today:

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* 24. Your primary language spoken:

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* 25. Patient gender:

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* 26. Patient race:

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* 27. Patient ethnicity:

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* 28. Patient age in years:

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* 29. Your last visit to a clinic:

Thank you for your time and comments. When you finish this survey you can enter a drawing for a $50 gift card that you can use at a number of stores in Lane County. Entry forms are available at your clinic site.

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