Information Card This survey has three parts - it tells us a little about you, asks you if you need our services right now, and lets you give your opinion about what you would like Guided Pathways - Support for Youth and Families to do. The survey is 4 questions and will not take very long to fill out. Once you have filled it out press the Done button at the end. The survey will be email to Guided Pathways - Support for Families. Question Title * 1. This is necessary information about you. Name: Company: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Country: Email Address: Phone Number: Question Title * 2. Choose as many as you would like.Would you like to: Be on our Newsletter Distribution Find out about Volunteer Opportunities Learn more about our Programs and Services Lead a class for parents Lead a class for youth Sponsor and event Other (please specify) Question Title * 3. Do you need our help NOW?When and how may we contact you? By Phone By Email Home Visit During the Day Monday-Friday During the Day Monday-Friday By Phone During the Day Monday-Friday By Email During the Day Monday-Friday Home Visit During the Evening Monday-Friday During the Evening Monday-Friday By Phone During the Evening Monday-Friday By Email During the Evening Monday-Friday Home Visit During the Weekend During the Weekend By Phone During the Weekend By Email During the Weekend Home Visit Other (please specify) Question Title * 4. What do you think GPS should focus on? 1=No 2=Cool to the idea 3=Maybe 4=Like that idea 5=Definately One-to-One Parent Support One-to-One Parent Support 1=No One-to-One Parent Support 2=Cool to the idea One-to-One Parent Support 3=Maybe One-to-One Parent Support 4=Like that idea One-to-One Parent Support 5=Definately Youth Peer Counseling Youth Peer Counseling 1=No Youth Peer Counseling 2=Cool to the idea Youth Peer Counseling 3=Maybe Youth Peer Counseling 4=Like that idea Youth Peer Counseling 5=Definately Information & Referral Line Information & Referral Line 1=No Information & Referral Line 2=Cool to the idea Information & Referral Line 3=Maybe Information & Referral Line 4=Like that idea Information & Referral Line 5=Definately Parent Classes Parent Classes 1=No Parent Classes 2=Cool to the idea Parent Classes 3=Maybe Parent Classes 4=Like that idea Parent Classes 5=Definately Family Social Events Family Social Events 1=No Family Social Events 2=Cool to the idea Family Social Events 3=Maybe Family Social Events 4=Like that idea Family Social Events 5=Definately Community Needs & Asset Assessment Community Needs & Asset Assessment 1=No Community Needs & Asset Assessment 2=Cool to the idea Community Needs & Asset Assessment 3=Maybe Community Needs & Asset Assessment 4=Like that idea Community Needs & Asset Assessment 5=Definately Advocacy Advocacy 1=No Advocacy 2=Cool to the idea Advocacy 3=Maybe Advocacy 4=Like that idea Advocacy 5=Definately Other (please specify) Thank you for your response. If you have any questions or would like to contact us please call 253-236-8264 or email, info@guidedpathways.org. Done
