* 1. Which program or programs have you participated in?  Please    check all that apply.

* 2. How was the enrollment or application process?

* 3. Agency staff treated me with respect and was sensitive to my
situation and needs.

* 4. Agency was able to meet my needs.

* 5. Agency staff were not able to meet my needs but I was referred to other resources.

* 6. How did you hear about us?

* 7. Do you have any additional comments?

* 8. Name (optional)

* 9. Would you like to be contacted?

* 10. Contact information (phone number, email, etc.)