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C.A.R.E. Customer Feedback
1.
What is your name?
2.
What is your age range?
Under 18
18-24
25-34
35-44
45-54
55-64
65+
3.
Gender: How do you identify?
Man
Non-binary
Woman
Prefer to self-describe, below
Self-describe:
4.
What is your race or ethnicity?
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Multiracial or Multiethnic
Native American or Alaska Native
Native Hawaiian or other Pacific Islander
White
Another race or ethnicity, please describe below
Self-describe below:
*
5.
What state do you reside in?
(Required.)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia (DC)
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other (please specify)
6.
Which C.A.R.E. services have you most recently received?
C.A.R.E. Family and Transportation Services
Mindful Hiking and Meditation Workshop
LaDe Travel Planning and Guide
C.A.R.E. Farmacy and Market
Private Consultation
Community Partnership
*
7.
How would you rate the quality of the service you received?
(Required.)
Very high quality
High quality
Neither high nor low quality
Low quality
Very low quality
Other (please specify)
*
8.
Would you do business with CARE, DBA LaDe again?
(Required.)
Yes
No
Maybe
Yes, and I wish to subscribe to the C.A.R.E. newsletter for upcoming news and events.
*
9.
Please provide an email address of a friend and/or family member who would be interested in C.A.R.E. services.
(Required.)