Social Services would love to hear your opinion!

Filling out this survey will not affect the services you get. 

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* 1. Today's Date (MM/DD/YYYY)

Date

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* 2. Name of SHIBA Counselor (Optional):

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* 3. Please select your answer about the service you received:

  Yes No Doesn't Apply to Me
I got the information I needed.
I got connected to the services I was looking for.
The person I worked with spent enough time with me to understand what I needed.
The person I worked with knew about helpful resources and services.
The person who worked with me treated me with respect.
The person who worked with me answered my questions.
I feel less lonely and/or isolated as a result of the services or information I got.
I am satisfied with this service.
The person who helped me was sensitive to my cultural/ethnic background.
I will recommend this service to other people.

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* 4. What did you like best about the services you received?

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* 5. How can we make our services better?

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* 6. Does your household have any unmet needs? If yes, what are your needs?

Demographic Information

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* 7. Gender

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* 8. Age

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* 9. Race/Ethnicity/Culture (Check all that apply):

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* 10. Would you like to talk with a staff member about your feedback? If so, give us your name and contact information. We will get back to you within 10 business days.

Thank you for your valuable time and input. Your opinion and feedback will help make sure that we provide the highest quality services to our community!

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