Section A

Please complete the following questions. These questions ask for some details about you in
order to help organize the information by sub-group for quality improvement purposes.

You may answer only the questions that you feel comfortable answering, and you may stop at any time.

Please tell us what type of service you or your loved one are receiving from the list below:

Question Title

* 1. Please tell us what type of service you or your loved one are receiving from the list below:

Age (please check one box)

Question Title

* 3. Age (please check one box)

T