Survey | Qualtrics Survey Software

Please take a few minutes to complete this one page form.

The form is seeking to particular touching or amazing stories because of your SHC. If your story is particularly touching and amazing they may be featured on the LPHI website, used for advocacy, or used to indicate to our funder how the SBHC's are helping others.

INSTRUCTIONS: Answer each question in a BRIEF (2-3 sentences) manner without revealing any identifying information for the patient or client.

YOUR INFORMATION

Your Name

Your title

Best phone number for contact

Your e-mail address

Your Health Centers Name

The patients story

Please describe the initial referral of the patient (maximum 500 characters)

(DO NOT USE IDENTIFYING INFORMATION)

Please describe the patients progress because of the intervention (maximum 500 characters)

(DO NOT USE IDENTIFYING INFORMATION)

Please predict what would have happened if the client had NOT received services (maximum 500 characters)

(DO NOT USE IDENTIFYING INFORMATION)

Please click "Submit" to complete the survey