Please provide the following information. The information is kept confidential and does not go into a permanent record. Please fill out the form, print a copy for your files, and click "DONE". PLEASE PRINT YOUR OWN COPY BEFORE YOU SUBMIT THE FORM. Thank you.


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* 1. Your Name (optional):

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* 2. Your school

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* 3. Date of crisis:

Date

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* 4. Type of Crisis

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* 5. Please check all services that P/I Center staff assisted with before or during the crisis:

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* 6. Were the services provided helpful? Check all that apply:

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* 7. What was the most helpful part of the response?

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* 8. How would you improve the Crisis Response Team & P/I Center response?

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* 9. Do you still require any assistance?

Please print a copy of this for your own records before you submit. Thank you.

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