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1. Which organization do you receive services from? (Required.)

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2. Which service(s) are you currently receiving? (Check all that apply) (Required.)

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3. Who is your service provider(s)? (Required.)

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4. Is your service provider dependable? (Required.)

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5. Are you treated with kindness and respect? (Required.)

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6. Are the services you are receiving helpful? (Required.)

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7. Do you receive services as often as you need? (Required.)

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8. Are you satisfied with your service provider? (Required.)

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9. Do you find that our environment is clean, safe & welcoming? (Required.)

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10. Do you have any additional comments, questions, or concerns you would like to share?

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