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Please fill in the form below.
All fields with an asterisk (*) are mandatory.
Full Name*
Gender*
Male
Female
Age*
Under 20 years old
20 – 29 years old
30 – 39 years old
40 – 49 years old
50 years old & above
Which of the following SOS service(s) did you use?*
Telephone hotline
Email Befriending
Counselling (face-to-face)
Healing Bridge support group
Attended a workshop, talk or forum
I have never used any SOS service
Others: (please specify)
If you had called the hotline, how easy was it to get through?*
Very easy (less than 3 attempts)
Fairly easy (3 – 5 attempts)
Not very easy (5 – 10 attempts)
Very difficult (more than 10 attempts)
Did not get through
Did not try calling
Others: (please specify)
If you had called the hotline and had problems getting through, could you tell us the date and time you tried?
Date :
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Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
2010
2011
Time :
On a scale of 1 to 10, how would you rate the support you received from SOS?*
(1 – Not helpful at all; 10 – very helpful)
Please Select
1
2
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5
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9
10
Not applicable
Comments
Your feedback is very important to us. We may need to contact you to assist us in our follow-up. How would you like SOS to contact you?
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Based on what you have written, can we quote you anonymously for our publicity?*
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