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* 1. Month/Year of Survey

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* 2. Office Region Location

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* 3. Services Received from AFS:

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* 4. Please Rate:

  1-Agree 2-Neutral 3-Disagree
My/My child’s symptoms have improved as a result of treatment received
Staff treated me/my family with respect for my cultural and personal preferences
I would recommend AFS to a friend who needed services

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* 5. If you are neutral or disagree with any of the statements, we would appreciate hearing your concerns or suggestions for improvement in the space below.

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* 6. If you would like for our agency to contact you to discuss these concerns, please indicate this and provide us with a contact number:

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