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* 1. Name

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* 2. Phone Number

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* 3. Email Address

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* 4. What made you choose this program as opposed to going to a clinic for outpatient therapy?

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* 5. If needed, are you likely to use us again or refer a friend or family member? Why or why not?

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* 6. On a scale from 0-10 (0=very dissatisfied, 10=very satisfied), how satisfied were you with the experience?

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* 7. Do you have any suggestions for improving the program?

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* 8. Any additional comments or specific praise you’d like to give your therapist(s)?

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