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

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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?

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* 5. Please indicate who you are

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* 6. Feedback was received on

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* 7. location

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

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

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* 10. Please enter your feedback here:

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

2. clients phone number

3. clients email address

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

5. Please indicate who you are

6. Feedback was received on

7. location

8. What type of comment would you like to provide

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

10. Please enter your feedback here: