client feedback

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* 1. Client's information (can be anonymous or your name)

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* 2. clients phone number

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* 3. clients email address

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* 4. If staff is filling out on client's behalf has consent been obtained?

Yes

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* 5. Please indicate who you are

client

family

other

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* 6. Feedback was received on

Date / Time

Date

Time

AM/PM

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* 7. location

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* 8. What type of comment would you like to provide

compliment

concern

feedback/suggestion

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* 9. Would you like someone from Scarborough Centre for Healthy Communities to follow up with you?

Yes

client feedback

Question Title

* 1. Client's information (can be anonymous or your name)

Question Title

* 2. clients phone number

Question Title

* 3. clients email address

Question Title

* 4. If staff is filling out on client's behalf has consent been obtained?

Question Title

* 5. Please indicate who you are

Question Title

* 6. Feedback was received on

Question Title

* 7. location

Question Title

* 8. What type of comment would you like to provide

Question Title

* 9. Would you like someone from Scarborough Centre for Healthy Communities to follow up with you?

Question Title

* 10. Please enter your feedback here: