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* 1. What is your age?

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* 2. What is your ethnicity? (Please select all that apply.)

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* 3. What is the highest level of education you have completed?

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* 4. Do you currently have health insurance, or not?

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* 5. What is your family type?

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* 6. Describe your housing situation.

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* 7. What services did we provide?

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* 8. Did staff assist you in a timely manner?

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* 9. Staff was courteous, respectful, friendly and helpful.

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* 10. My overall service experience was positive.

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