This form is for giving feedback about your interactions on the UpliftWI peer support warmline. You are encouraged to share positive and negative experiences, and suggestions for how we could improve. If you would like to have a follow up conversation with an UpliftWI supervisor, you may leave your contact information, but this is not required. Your input can help us improve upon this resource, and we appreciate you taking the time to give feedback!

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* 1. How satisfied were you with your conversation on the UpliftWI peer support line? Please rate on a scale of 0 (not at all satisfied) and 100 (extremely satisfied) 

0 50 100
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i We adjusted the number you entered based on the slider’s scale.

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* 2. Please use this space to share what you want us to know about your conversation on the UpliftWI line (optional) 

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* 3. If you would like to share the date and time of your call, enter here:

Date
Time

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* 4. If you know the name of the peer operator that you spoke with, you can enter it here: 

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* 5. Please check this box if you would like to request a follow up conversation with an UpliftWI supervisor. Skip if you do not need follow up. 

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* 6. Your contact information (optional, only needed if you want a follow up conversation) 

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