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Surveys
2013
December
C
Client Satisfaction Survey
Client Satisfaction Survey
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Please help us improve our services by giving confidential feedback about your experience at CCCE. Mark the answer which most closely represents your experience.
Thank you,
Jan Ewing, PhD.
Therapist ID#
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Demographics
Cultural Heritage
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African
African American
Asian
Caucasian / White
Latino/a
Middle Eastern
Native American
Pacific Islander
Decline to state
Other
Language
Age Range
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0-17
18-24
25-30
31-35
36-40
41-50
51-60
61-70
70+
Gender
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Female
Male
gender Queer
Transgender (Male to Female)
Transgender (Female to Male)
Other
Religious Affiliation
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Christian / Catholic
Jewish
Muslim
Hindi
Buddhist
Tribal
Agnostic
Atheist
Spiritual
Unitarian Universalist
Jehovah Witness
Decline to State
Other
Sexual Orientation
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Heterosexual
Queer
Gay
Lesbian
Bisexual
Pansexual
Questioning
Complicated
Unknown / Decline to state
Other
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