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<br /> <br /> <br />My new address is: ________________________________________________________ <br /> <br />_____ I have taken my linens back to staff and I have thoroughly cleaned my area. <br />_____ I have picked up any medication and mail from the staff office. <br /> <br />How were we helpful to you? <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br /> <br />What changes (negative/positive) do you feel that you have made in your life as a result <br />of your stay here? <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br /> <br />What changes do you think your children have made? <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br /> <br />What did you especially like about your stay here? <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br /> <br />What did you not like and why? <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br /> <br />How do you think our program could be improved? <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br /> <br />Do you feel that you received the assistance you needed? <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br /> <br />154