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Social Questionnaire
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Name (First and Last)
*
Your answer
Age
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
City of Residence
*
Your answer
I would like a regular social activity to do every day.
Yes
No
Clear selection
I would like to meet other people who have similar interests.
Yes
No
Clear selection
I would like to find a place where I feel like I can belong.
Yes
No
Clear selection
I am nervous about meeting new people or going to new places.
Yes
No
Clear selection
I would prefer a Social Mentor over my family members to assist me with social needs.
Yes
No
Clear selection
What questions do you have about Social?
Your answer
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