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* 1. Treatment You Received/Provider Name

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* 2. What Services Did You Receive 

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* 3. I was treated with courtesy by the office staff

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* 4. I was treated respectful by my provider

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* 5. My treatment provider(s) helped me with my concern

  Strongly Agree  Agree  Disagree  Strongly Disagree  N/A
Peer Support 
Counseling 
CBRS 

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* 6. I would recommend my provider to others

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* 7. Please Indicate What Best Describes You

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* 8. Do you have any other comments, questions, or concerns?

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