1. Purpose of Survey

25% of survey complete.
The purpose of this survey is to evaluate the effectiveness of services provided by MPACT. It is to be filled out by those who received phone or in-person assistance from MPACT.

Everyone who completes a survey will be entered into a drawing for a $25 gift certificate from your choice of the following stores: Wal-Mart, K-Mart, Target, Staples, or Office Depot.

All fields with an * require an answer before allowing you to proceed to the next page.

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* 1. Please enter the approximate date you received assistance from MPACT.


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* 2. MPACT Staff member or Mentor who assisted you:

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* 3. Primary question or concern of this contact:

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* 4. Please enter your County: