{"id":1317,"date":"2026-08-20T18:01:59","date_gmt":"2026-08-20T18:01:59","guid":{"rendered":"https:\/\/chipolahealthystart.org\/?page_id=1317"},"modified":"2026-08-20T18:02:44","modified_gmt":"2026-08-20T18:02:44","slug":"satisfaction-survey","status":"publish","type":"page","link":"https:\/\/chipolahealthystart.org\/index.php\/satisfaction-survey\/","title":{"rendered":"Satisfaction Survey"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1317\" class=\"elementor elementor-1317\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-f6d0b20 e-flex e-con-boxed e-con e-parent\" data-id=\"f6d0b20\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-8a7b38c fluent-form-widget-step-header-yes fluent-form-widget-step-progressbar-yes fluentform-widget-submit-button-custom elementor-widget elementor-widget-fluent-form-widget\" data-id=\"8a7b38c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"fluent-form-widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n            <div class=\"fluentform-widget-wrapper fluentform-widget-align-default\">\n\n            \n            <div class='fluentform ff-default fluentform_wrapper_7 ffs_default_wrap'><form data-form_id=\"7\" id=\"fluentform_7\" class=\"frm-fluent-form fluent_form_7 ff-el-form-top ff_form_instance_7_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_7_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Satisfaction Survey<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='1317' \/><input type=\"hidden\" id=\"_fluentform_7_fluentformnonce\" name=\"_fluentform_7_fluentformnonce\" value=\"1c2b3bd23e\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/1317\" \/><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-7_1\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><p>Please score the following questions 1-5, 1 being <strong>Strongly disagree<\/strong> and 5 being\u00a0<strong>Strongly agree.<\/strong><strong><br \/><\/strong><\/p><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"You were offered an appointment time convenient for you.\">You were offered an appointment time convenient for you.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_601f69389a8cf3eea6ebf90c1a7d89c9'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"1\"  id='checkbox_601f69389a8cf3eea6ebf90c1a7d89c9' aria-label='1' aria-invalid='false' aria-required=true> <span>1<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_a47f64c85eefe06e00eb0a442d55ddeb'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"2\"  id='checkbox_a47f64c85eefe06e00eb0a442d55ddeb' aria-label='2' aria-invalid='false' aria-required=true> <span>2<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_dda03b64e703600ff6ad37601a2fc436'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"3\"  id='checkbox_dda03b64e703600ff6ad37601a2fc436' aria-label='3' aria-invalid='false' aria-required=true> <span>3<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_37a26781fb39e12d8a5f8958f26470b8'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"4\"  id='checkbox_37a26781fb39e12d8a5f8958f26470b8' aria-label='4' aria-invalid='false' aria-required=true> <span>4<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_8f28d7fecba75bc954bbdf410b0d26c2'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"5\"  id='checkbox_8f28d7fecba75bc954bbdf410b0d26c2' aria-label='5' aria-invalid='false' aria-required=true> <span>5<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"The Heathy Start Care Coordinator provided me helpful information.\">The Heathy Start Care Coordinator provided me helpful information.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_dfb77d05692a9b33f0e3cec93d608f4b'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"1\"  id='checkbox_1_dfb77d05692a9b33f0e3cec93d608f4b' aria-label='1' aria-invalid='false' aria-required=true> <span>1<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_7925f14c068895021b14a1329b888cf3'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"2\"  id='checkbox_1_7925f14c068895021b14a1329b888cf3' aria-label='2' aria-invalid='false' aria-required=true> <span>2<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_b0d051cff51309d73346a2496d6304d9'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"3\"  id='checkbox_1_b0d051cff51309d73346a2496d6304d9' aria-label='3' aria-invalid='false' aria-required=true> <span>3<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_73706da831f9f31464c14dd4490a170c'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"4\"  id='checkbox_1_73706da831f9f31464c14dd4490a170c' aria-label='4' aria-invalid='false' aria-required=true> <span>4<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_ea13dc1603c034630a5785d30d92bd94'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"5\"  id='checkbox_1_ea13dc1603c034630a5785d30d92bd94' aria-label='5' aria-invalid='false' aria-required=true> <span>5<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"I felt comfortable sharing my concerns with the Healthy Start Care  Coordinator.\">I felt comfortable sharing my concerns with the Healthy Start Care  Coordinator.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_a6aba4aaedc8537961674044051dc3a2'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"1\"  id='checkbox_2_a6aba4aaedc8537961674044051dc3a2' aria-label='1' aria-invalid='false' aria-required=true> <span>1<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_972ac05632301fab6e672b7e9005fd12'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"2\"  id='checkbox_2_972ac05632301fab6e672b7e9005fd12' aria-label='2' aria-invalid='false' aria-required=true> <span>2<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_68f2676ae78061cbf372ebc4d57d37f4'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"3\"  id='checkbox_2_68f2676ae78061cbf372ebc4d57d37f4' aria-label='3' aria-invalid='false' aria-required=true> <span>3<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_a5114992ccea41dd806f65428df2dbc3'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"4\"  id='checkbox_2_a5114992ccea41dd806f65428df2dbc3' aria-label='4' aria-invalid='false' aria-required=true> <span>4<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_eccdb6aeca72057b7d89f7f2bff8b544'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"5\"  id='checkbox_2_eccdb6aeca72057b7d89f7f2bff8b544' aria-label='5' aria-invalid='false' aria-required=true> <span>5<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"The Care Coordinator was friendly and supportive.\">The Care Coordinator was friendly and supportive.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3_d57bb7ae6cf4ff96ced8fd886a835e7a'><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"1\"  id='checkbox_3_d57bb7ae6cf4ff96ced8fd886a835e7a' aria-label='1' aria-invalid='false' aria-required=true> <span>1<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3_f2a8779539b45e4602f6344ebfe16b19'><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"2\"  id='checkbox_3_f2a8779539b45e4602f6344ebfe16b19' aria-label='2' aria-invalid='false' aria-required=true> <span>2<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3_bc56843300c9976e5c01167f6bfc6fd2'><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"3\"  id='checkbox_3_bc56843300c9976e5c01167f6bfc6fd2' aria-label='3' aria-invalid='false' aria-required=true> <span>3<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3_80a81e9468952e8b5c74211acd6bcc3b'><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"4\"  id='checkbox_3_80a81e9468952e8b5c74211acd6bcc3b' aria-label='4' aria-invalid='false' aria-required=true> <span>4<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3_cbf852e6fad3749582c279fb8746e677'><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"5\"  id='checkbox_3_cbf852e6fad3749582c279fb8746e677' aria-label='5' aria-invalid='false' aria-required=true> <span>5<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"The Care Coordinator explained the Healthy Start program in a way  that I could understand.\">The Care Coordinator explained the Healthy Start program in a way  that I could understand.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4_f3c0286968aeec258ce1cef2ee0da770'><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"1\"  id='checkbox_4_f3c0286968aeec258ce1cef2ee0da770' aria-label='1' aria-invalid='false' aria-required=true> <span>1<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4_875214b838fbc07c187fd766509d19e4'><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"2\"  id='checkbox_4_875214b838fbc07c187fd766509d19e4' aria-label='2' aria-invalid='false' aria-required=true> <span>2<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4_ad1603ec03cc2fea15a7a65a8881ed60'><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"3\"  id='checkbox_4_ad1603ec03cc2fea15a7a65a8881ed60' aria-label='3' aria-invalid='false' aria-required=true> <span>3<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4_2f35491c52b5c9599758d392a8fd13e7'><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"4\"  id='checkbox_4_2f35491c52b5c9599758d392a8fd13e7' aria-label='4' aria-invalid='false' aria-required=true> <span>4<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4_b820e5319f019a96e39368f4299986ff'><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"5\"  id='checkbox_4_b820e5319f019a96e39368f4299986ff' aria-label='5' aria-invalid='false' aria-required=true> <span>5<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"While in the Healthy Start Program, I received information about  how to take care of myself and my baby.\">While in the Healthy Start Program, I received information about  how to take care of myself and my baby.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_6_0452c25ea54c63207d5eb2a99192d94b'><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"1\"  id='checkbox_6_0452c25ea54c63207d5eb2a99192d94b' aria-label='1' aria-invalid='false' aria-required=true> <span>1<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_6_bfbc8ab3bec75d862ad601e2f1451b28'><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"2\"  id='checkbox_6_bfbc8ab3bec75d862ad601e2f1451b28' aria-label='2' aria-invalid='false' aria-required=true> <span>2<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_6_d55f4fbdabc9a70a0aed8dc73cd31786'><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"3\"  id='checkbox_6_d55f4fbdabc9a70a0aed8dc73cd31786' aria-label='3' aria-invalid='false' aria-required=true> <span>3<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_6_b789c2e58827a59f64ebc12b46c84d01'><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"4\"  id='checkbox_6_b789c2e58827a59f64ebc12b46c84d01' aria-label='4' aria-invalid='false' aria-required=true> <span>4<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_6_92779177d8cd2cfb8bbbcf8169f52567'><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"5\"  id='checkbox_6_92779177d8cd2cfb8bbbcf8169f52567' aria-label='5' aria-invalid='false' aria-required=true> <span>5<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Was the Healthy Start Program useful to you?\">Was the Healthy Start Program useful to you?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_7_c6136c7c32d5b188d1a1b9975a2590bd'><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"1\"  id='checkbox_7_c6136c7c32d5b188d1a1b9975a2590bd' aria-label='1' aria-invalid='false' aria-required=true> <span>1<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_7_0c1539de069ce21b293f14defe8ef436'><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"2\"  id='checkbox_7_0c1539de069ce21b293f14defe8ef436' aria-label='2' aria-invalid='false' aria-required=true> <span>2<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_7_64f94b670410071aeef14a74025d6b6f'><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"3\"  id='checkbox_7_64f94b670410071aeef14a74025d6b6f' aria-label='3' aria-invalid='false' aria-required=true> <span>3<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_7_b7f14610899af8b02af60e61251e8867'><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"4\"  id='checkbox_7_b7f14610899af8b02af60e61251e8867' aria-label='4' aria-invalid='false' aria-required=true> <span>4<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_7_325086a9a3731907b198a9799d1201b4'><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"5\"  id='checkbox_7_325086a9a3731907b198a9799d1201b4' aria-label='5' aria-invalid='false' aria-required=true> <span>5<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-7_2\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"The Healthy Start Care Coordinator directed me to other agencies  in the community to assist me.\">The Healthy Start Care Coordinator directed me to other agencies  in the community to assist me. <\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_5_27ffb4241fa2457d4e48a5dbdd6855bf'><input  type=\"checkbox\" name=\"checkbox_5[]\" data-name=\"checkbox_5\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_5_27ffb4241fa2457d4e48a5dbdd6855bf' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_5_f3fe821f186a00dc8bf5308f01ae62f0'><input  type=\"checkbox\" name=\"checkbox_5[]\" data-name=\"checkbox_5\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_5_f3fe821f186a00dc8bf5308f01ae62f0' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_5_8606708f185b4b59d7d68d7705620f31'><input  type=\"checkbox\" name=\"checkbox_5[]\" data-name=\"checkbox_5\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"N\/A\"  id='checkbox_5_8606708f185b4b59d7d68d7705620f31' aria-label='N\/A' aria-invalid='false' aria-required=true> <span>N\/A<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"My visit time\/duration was\">My visit time\/duration was <\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_8_e0d63cb559eb3be04f4ce1461cbb97f5'><input  type=\"checkbox\" name=\"checkbox_8[]\" data-name=\"checkbox_8\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Longer than I expected\"  id='checkbox_8_e0d63cb559eb3be04f4ce1461cbb97f5' aria-label='Longer than I expected' aria-invalid='false' aria-required=true> <span>Longer than I expected<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_8_294cc554a96f7c9673c4f6d90c3c07e6'><input  type=\"checkbox\" name=\"checkbox_8[]\" data-name=\"checkbox_8\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Duration that I expected\"  id='checkbox_8_294cc554a96f7c9673c4f6d90c3c07e6' aria-label='Duration that I expected' aria-invalid='false' aria-required=true> <span>Duration that I expected<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_8_6ccccbf5f8d3e263f7501f33ea68a221'><input  type=\"checkbox\" name=\"checkbox_8[]\" data-name=\"checkbox_8\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Shorter than I expected\"  id='checkbox_8_6ccccbf5f8d3e263f7501f33ea68a221' aria-label='Shorter than I expected' aria-invalid='false' aria-required=true> <span>Shorter than I expected<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Would you recommend our services to a friend?\">Would you recommend our services to a friend?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_9_7ffe1b1bc353d1a635d917b840fe9401'><input  type=\"checkbox\" name=\"checkbox_9[]\" data-name=\"checkbox_9\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_9_7ffe1b1bc353d1a635d917b840fe9401' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_9_49e41e5d17f8b3ac7fa8a8d8171716e3'><input  type=\"checkbox\" name=\"checkbox_9[]\" data-name=\"checkbox_9\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_9_49e41e5d17f8b3ac7fa8a8d8171716e3' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_input_text' id='label_ff_7_input_text' aria-label=\"Why, or why not?\">Why, or why not?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" maxlength=\"200\" data-name=\"input_text\" id=\"ff_7_input_text\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_7_input_text_1' id='label_ff_7_input_text_1' aria-label=\"Would you like to share anything else?\">Would you like to share anything else?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" maxlength=\"200\" data-name=\"input_text_1\" id=\"ff_7_input_text_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-7_3\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Race\">Race<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_11_3946f0312efaa84fbddedc2692939490'><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"White\"  id='checkbox_11_3946f0312efaa84fbddedc2692939490' aria-label='White' aria-invalid='false' aria-required=true> <span>White<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_11_abb618116257745b9c2055ea093fb29c'><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Black\/African American\"  id='checkbox_11_abb618116257745b9c2055ea093fb29c' aria-label='Black\/African American' aria-invalid='false' aria-required=true> <span>Black\/African American<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_11_eb71f7e2050ffe3d78e5e57bda6a3576'><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Asian\"  id='checkbox_11_eb71f7e2050ffe3d78e5e57bda6a3576' aria-label='Asian' aria-invalid='false' aria-required=true> <span>Asian<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_11_348746e558b2bda3662e508b4bcd0789'><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Pacific Islander\"  id='checkbox_11_348746e558b2bda3662e508b4bcd0789' aria-label='Pacific Islander' aria-invalid='false' aria-required=true> <span>Pacific Islander<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_11_3a0cff2dcf33a4272d72d1ebd265be46'><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Native American\/American Indian\"  id='checkbox_11_3a0cff2dcf33a4272d72d1ebd265be46' aria-label='Native American\/American Indian' aria-invalid='false' aria-required=true> <span>Native American\/American Indian<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_11_68febbde0991f7616fd8be1abb60a376'><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Multiracial\"  id='checkbox_11_68febbde0991f7616fd8be1abb60a376' aria-label='Multiracial' aria-invalid='false' aria-required=true> <span>Multiracial<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_11_b204428202af73b381b905dcbdd27a60'><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Prefer not to share\"  id='checkbox_11_b204428202af73b381b905dcbdd27a60' aria-label='Prefer not to share' aria-invalid='false' aria-required=true> <span>Prefer not to share<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Ethnicity\">Ethnicity<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_12_802bccb5e85ad66d3666c0126bd962e2'><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Hispanic\/Latino\/Spanish origin\"  id='checkbox_12_802bccb5e85ad66d3666c0126bd962e2' aria-label='Hispanic\/Latino\/Spanish origin' aria-invalid='false' aria-required=true> <span>Hispanic\/Latino\/Spanish origin<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_12_644458ea34e77825e58de7aa44208665'><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Haitian origin\"  id='checkbox_12_644458ea34e77825e58de7aa44208665' aria-label='Haitian origin' aria-invalid='false' aria-required=true> <span>Haitian origin<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_12_30520be5ea70e1fe416d2b5c89d10606'><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Not Hispanic\/Hatian origin\"  id='checkbox_12_30520be5ea70e1fe416d2b5c89d10606' aria-label='Not Hispanic\/Hatian origin' aria-invalid='false' aria-required=true> <span>Not Hispanic\/Hatian origin<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_12_92f5d18308f2b599c586f6606b43ef53'><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Prefer not to share\"  id='checkbox_12_92f5d18308f2b599c586f6606b43ef53' aria-label='Prefer not to share' aria-invalid='false' aria-required=true> <span>Prefer not to share<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_dropdown' id='label_ff_7_dropdown' aria-label=\"Please select the county you live in.\">Please select the county you live in. <\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown\" id=\"ff_7_dropdown\" class=\"ff-el-form-control\" data-name=\"dropdown\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_7_dropdown\"><option value=\"\">- Select -<\/option><option 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