THIS SURVEY IS COMPLETELY VOLUNTARY.

RESPONSES TO THIS SURVEY MUST NOT CONTAIN ANY CONFIDENTIAL OR PROTECTED HEALTH INFORMATION PERTAINING TO INDIVIDUALS RECEIVING SERVICES. THIS INCLUDES IDENTIFIABLE DEMOGRAPHIC DATA, INFORMATION ABOUT THE PHYSICAL OR MENTAL HEALTH CONDITION(S) OF AN INDIVIDUAL, OR ANY INFORMATION REGARDING TREATMENT REGIMENS OR PAYMENT HISTORY FOR HEALTHCARE SERVICES PROVIDED TO AN INDIVIDUAL.

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