Please provide the following information:
Client Unique Identification Code:
Date Tested:
Your Gender (Male or Female):
Your Age:
Additional information:
What is your primary ethnic/cultural/racial background?	American Ind./AK Native Asian Black/African American Native HI/Pac. Islander White Don't Know Declined
How did you find out about HIV Counseling and Testing at Face to Face Enrichment Center (Face to Face)?	Referral Agency Advertisement Word of Mouth Other
When thinking about the HIV testing session you recently completed, how satisfied were you with the expertise/knowledge of your counselor?	Very satisfied Somewhat satisfied Neutral Unsatisfied Very unsatisfied
When thinking about the HIV testing session you recently completed, how satisfied were you with the pleasantness/friendliness of your counselor?	Very satisfied Somewhat satisfied Neutral Unsatisfied Very unsatisfied
For you personally, how important is it to try/use the risk reduction strategies identified during the counseling session as a method of increasing your sexual health and safety?	Very important to me Somewhat important to me Neutral Not important to me Not at all important to me
Please rate your overall testing experience with Face to Face?	Excellent Good Average Fair Poor Not applicable
How likely is it that you would refer Face to Face's HIV testing services to a friend and/or partner?	Very likely Somewhat likely Neutral Unlikely Very unlikely