4-Month Follow-Up Questionnaire
Please complete this form to help us understand your progress and experience since your initial participation four months ago.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Initial Participation or Enrollment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Since your initial participation, how would you rate your overall progress?
*
1
2
3
4
5
Please indicate your level of satisfaction with the following areas:
*
Rows
Communication
Support Received
Resources Provided
Overall Experience
Very Dissatisfied
1
2
3
4
Dissatisfied
5
6
7
8
Neutral
9
10
11
12
Satisfied
13
14
15
16
Very Satisfied
17
18
19
20
What challenges or obstacles have you encountered in the past four months?
Have you achieved the goals you set at the start of the program?
*
Yes
Partially
No
Which of the following support resources have you used in the last four months? (Select all that apply)
Online Materials
Workshops/Seminars
One-on-One Support
Peer Groups
Other
What changes, if any, would you suggest to improve our program or services?
Are you interested in participating in additional follow-up or support activities?
Yes
No
Maybe
Please provide any additional comments or feedback.
Submit
Should be Empty: