Membership Feedback Form Feedback Form How did you hear about Hope for Two The Pregnant with Cancer Network? - Select One - By Searching the Web Referred by family or friend Referred by physician Referred by other health care provider Referred by social worker Referred by other service provider Read Hope for Two�The Pregnant with Cancer Network literature which I received from Other How did you initially contact Hope for Two? - Select One - Applied for Support via on-line form on Web Site Telephone Mail Other Were you satisfied with our response time after you first contacted Hope for Two? Very Satisfied - 5 4 3 2 1 - Very Dissatisfied After hearing from our Patient Coordinator do you feel you had a good understanding of Hope for Two and how the Network works? - Select One - Yes No Were you satisfied with the timeliness of your initial contact with your support woman? - Select One - Yes No Are you satisfied with the frequency with which you are in contact with your support woman? Very Satisfied - 5 4 3 2 1 - Very Dissatisfied Based upon your experience, what issue(s) do you and your support woman typically discuss? (Check all that apply) Emotional Physical Medical Family Others How satisfied are you with your relationship with your support woman? Very Satisfied - 5 4 3 2 1 - Very Dissatisfied Has Hope for Two been helpful to you? Very Satisfied - 5 4 3 2 1 - Very Dissatisfied Would you recommend Hope for Two to a friend or family member? - Select One - Yes No What suggestions do you have that would help us strengthen our program? Any other comments, questions, or suggestions?
