Name *

First Name

Last Name

Phone *

(###)

###

####

Did you complete all sessions of the program? *

Yes

No

Do you plan on using the online COPE Program? *

Yes

No

What was your overall impression of the program in terms of how helpful it would be to your patients or students? *

Not at all helpful

A little helpful

Somewhat helpful

Moderately helpful

Very helpful

Would you like us to contact you with details on how to order the program? *

Yes

Maybe, I need time to evaluate the results

No, not at this time