Your feedback is important! | Family Health Initiatives

How are you doing? It has been several weeks since we first connected. Please take a moment to complete this quick survey to let us know how you are doing.

* Indicates a required field.

What was the name of the Referral Specialist you spoke with?*

When you spoke to the Referral Specialist, did they invite you to enroll in a home visiting program?*

Yes
No

Did you enroll?*

Yes
No

Please briefly explain why you enrolled:*

Please briefly explain why you did not enroll:*

Would you recommend this text message program to a friend?*

Yes
No

Would you recommend this Referral Specialist to a friend?*

Yes
No

Please indicate your level of agreement or disagreement with the following statements:

The Referral Specialist listened to my concerns and questions.*

The Referral Specialist gave me useful referrals and resources.*

The Referral Specialist is contacting me...*

Not often enough
Just enough
Too much

Which of these was the Referral Specialist most helpful with?*

(Please check all that apply)

My health
My pregnancy
My baby (Birth to 12 months)
My child (Age 1 to 5)
My child (Older than 5)
Making ends meet

What types of referrals or information do you still need more of?*

(Please check all that apply)

My health
My pregnancy
My baby (Birth to 12 months)
My child (Age 1 to 5)
My child (Older than 5)
Making ends meet

Please feel free to write any more comments or recommendations…

(Optional)