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B4L Client feedback form
Please help your clients answer these questions. If they are able to read on their own, let them answer on their own.
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What is your name?
Your answer
What is the date?
MM
/
DD
/
YYYY
What is the name of the staff that work with you?
Your answer
Do you go to work?
Yes
No
Clear selection
Do you like the place that you work?
Yes
No
Clear selection
Does your program help you make friends?
Yes
No
Clear selection
Does your program help you focus on things that you want to?
Yes
No
Maybe
Other:
Clear selection
Are your staff nice?
Yes
No
Maybe
Other:
Clear selection
Is the boss of your program easy to get ahold of?
Yes
No
Maybe
Other:
Clear selection
Would you change anything about your program?
Your answer
Do you have access to a phone if you need it?
Yes
No
Maybe
Other:
Clear selection
Do you know who to talk to when you have a problem?
Yes
No
Maybe
Other:
Clear selection
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