* 1. Date of appointment: *

* 2. Person you met with: *

* 3. Location of appt (Provide Organization, City, and CAN) *

* 4. Coordinated Access Network Support Survey: (Please rate your overall experience working with the CAN staff by answering the following statements from a scale of 1 to 5. ) *

  Strongly agree Agree Neither agree nor disagree Disagree Strongly Disagree
The person who I met with was easy to talk to and understood my needs.
I was satisfied with the ease of getting a CAN appointment.
I was satisfied with my overall experience at the CAN appointment.
I felt that the person I met with is doing a good job to meet my needs.
I was actively included in all planning.
All staff were sensitive to my cultural/ethnic background.
CAN staff was knowledge about available resources.

* 5. Any additional comments or suggestions you would like to share?