Survey for Applicants to Assess CSBG Services.

Question Title

* 1. May we kindly inquire about the entity that aided you with your YCAN application completion today?

First Stop Help Center of Park County

Help Center in Thermopolis

Park County Court Supervised Treatment Program

Active in Recovery

Open Space Counseling

Other (please specify)

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* 2. What services did you require assistance with today?

Housing Assistance

Homeless

Emergency (fire, flood, natural disaster, other emergency)

Disabled on a fixed income

Elderly 65+ living on a fixed income

Substance Abuse Disorder

Single Parent on fixed income

One Time Financial Crisis

Employment Supports

Transportation Supports

None of the above

Please specify if there is any other information you would like to provide.

Question Title

* 3. How satisfied are you with the assistance provided by the case manager in completing your applications today?

	No Opinion	Poor	Fair	Good	Excellent
How was your experience with your case manager?	How was your experience with your case manager? No Opinion	How was your experience with your case manager? Poor	How was your experience with your case manager? Fair	How was your experience with your case manager? Good	How was your experience with your case manager? Excellent
Were you able to receive the necessary services from the case manager?	Were you able to receive the necessary services from the case manager? No Opinion	Were you able to receive the necessary services from the case manager? Poor	Were you able to receive the necessary services from the case manager? Fair	Were you able to receive the necessary services from the case manager? Good	Were you able to receive the necessary services from the case manager? Excellent
Has your case manager fulfilled their promises to you?	Has your case manager fulfilled their promises to you? No Opinion	Has your case manager fulfilled their promises to you? Poor	Has your case manager fulfilled their promises to you? Fair	Has your case manager fulfilled their promises to you? Good	Has your case manager fulfilled their promises to you? Excellent
Could you please provide your rating of the YCAN application process?	Could you please provide your rating of the YCAN application process? No Opinion	Could you please provide your rating of the YCAN application process? Poor	Could you please provide your rating of the YCAN application process? Fair	Could you please provide your rating of the YCAN application process? Good	Could you please provide your rating of the YCAN application process? Excellent
How was your experience with your case manager overall?	How was your experience with your case manager overall? No Opinion	How was your experience with your case manager overall? Poor	How was your experience with your case manager overall? Fair	How was your experience with your case manager overall? Good	How was your experience with your case manager overall? Excellent
Have you received a response from YCAN regarding your application in a timely manner?	Have you received a response from YCAN regarding your application in a timely manner? No Opinion	Have you received a response from YCAN regarding your application in a timely manner? Poor	Have you received a response from YCAN regarding your application in a timely manner? Fair	Have you received a response from YCAN regarding your application in a timely manner? Good	Have you received a response from YCAN regarding your application in a timely manner? Excellent

Other (please specify)

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* 4. What city or town do you live in?

Powell

Cody

Thermopolis

Other (please specify)

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* 5. Could you please provide your county of residence?

Park County

Hot Springs County

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* 6. Could you please share your age with us?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 7. Are YCAN services meeting your needs effectively?

Extremely effective

Very effective

Somewhat effective

Not so effective

Not at all effective

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* 8. How likely is it that you would recommend this service to a friend or colleague?

NOT AT ALL LIKELY

EXTREMELY LIKELY

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* 9. Did you require any services today that you were unable to acquire?

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* 10. Is there anything you think we could do better to enhance our service to you?

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* 11. To be in with a chance of winning a Gift Card, kindly provide your contact information.

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number