1.What service(s) did you receive assistance in?

HEAP (Utility Assistance)

Emergency Services (rent, gas cards, hygiene/cleaning kits, transportation)

HWAP (Weatherization)

Referred to another program

2.If you did not receive assistance or needed further assistance, did the agency provide additional resources?

Yes

No additional services were needed

If yes, what other services were needed: 

3.How did you hear about our services or programs?

word of mouth (ex. a friend, family member, or neighbor)

past experience with our office

website/social media

referred by another agency

If Other (please specify)

4.Were the resources you needed available and easy to access?

Yes

No

5.Would you recommend our services to a friend or family member?

Yes

No

6.How responsive have we been to your questions or concerns about our services?

Extremely responsive

Very responsive

Somewhat responsive

Not so responsive

Not at all responsive

7.Overall, how would you rate the quality of your customer service?

Very satisfied

Satisfied

Neither satisfied nor dissatisfied

Dissatisfied

Very dissatisfied

8.What could we do better?  Is there anything else we could do to better serve you or the community?

9.Optional: Would you be interested in sharing your personal story with us?  If yes, please provide your name and contact information below

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number