Feedback Survey

1. Treat you with respect?

1 = extremely poor

2 = poor

3 = fair

4 = good

5 = excellent

2. Respect your culture, race, ethnicity, or religion?

1 = extremely poor

2 = poor

3 = fair

4 = good

5 = excellent

3. Did we address you properly?

1 = extremely poor

2 = poor

3 = fair

4 = good

5 = excellent

4. Make you feel okay about asking for help?

1 = extremely poor

2 = poor

3 = fair

4 = good

5 = excellent

5. Make you feel that you can help yourself and your family?

1 = extremely poor

2 = poor

3 = fair

4 = good

5 = excellent

The final questions will help us understand who the Hotline is supporting and who we may not be reaching.

1. How do you identify yourself?

Male

Female

Transgender male

Transgender female

Non-Binary

Prefer not to say

4. Checkbox

Which of the following best describes your race and/ or ethnicity? (Please select all that apply.)

American Indian/ Alaska Native

Native Hawaiian/ Other Pacific Islander

Asian

White

Black or African American

Hispanic/Latino