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Exit Survey
First name
Last name
I feel my wellbeing is
VERY POOR and this has a PROFOUND NEGATIVE impact on my daily life
QUITE POOR and this has a NEGATIVE impact on my daily life
OKAY and only SOMETIMES NEGATIVELY impacts my daily life
QUITE GOOD and only OCCASIONALLY NEGATIVELY impacts my daily life
VERY GOOD and RARELY IF EVER NEGATIVELY impacts my daily life
How I feel about manging my home
I know NOTHING about managing my home
I know A LITTLE about managing my home
I have REASONABLE KNOWLEDGE about managing my home
I have GOOD KNOWLEDGE about managing my home
I have VERY GOOD KNOWLEDGE about managing my home
I feel my family wellbeing is
VERY POOR and this has a PROFOUND NEGATIVE impact on my daily life
QUITE POOR and this has a NEGATIVE impact on my daily life
OKAY and only SOMETIMES NEGATIVELY impacts my daily life
QUITE GOOD and only OCCASIONALLY NEGATIVELY impacts my daily life
VERY GOOD and RARELY IF EVER NEGATIVELY impacts my daily life
I describe my connection to the community as
I am VERY ISOLATED. I have VERY LITTLE contact with friends, family or people in the community
I am FAIRLY isolated. I have LITTLE contact with friends, family, or people in the community
I feel SOMEWHAT connected. I have SOME contact with friends, family, or people in the community
I feel FAIRLY connected. I have a REASONABLE amount of contact with friends, family, or people in the community
I feel VERY connected. I have A LOT of contact with friends or family, or people in the community
How do you feel the service listened to you
The service DOES NOT listen or understand my issues at all
The service listens a LITTLE BIT or understands SOME of mjy issues
The service SOMETIMES listens or understands my issues
The service listens to me and understands A LOT of the time
The service ALWAYS listens to me and understands my issues
How satisfied are you of the service
I am NOT satisfied
I am a LITTLE satisfied
The service was OK
I am MOSTLY satisfied
I am VERY satisfied
Are you abe to better deal with issues that you sought help with
My ability to deal with issues I sought help with is the SAME
I can OCCASIONALLY deal with the issues I sought help with
SOMETIMES I can deal with issues I sought help with
MOST OFTEN I am able to deal with the issues I sought help with
I am ALWAYS able to deal with the issues I sought help with
Submit
Your survey has been submitted. Thankyou!
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