VAdata Add Communty-Based Services Feedback Survey Record

VAdata

Add Communty-Based Services Feedback Survey Record

Date Received: (Select)
Agency Number:
The information you provide will be shared and used to improve services in your community and across Virginia. Feel free to skip any question you are not comfortable answering.
1) How long have you been receiving services? (please check one)

Less than a week

1 week to 1 month

More then 1 month, but less than 3 months

More than 3 months

2) If a friend of mine was thinking of coming here for help, I would: (please check one)

Strongly recommend coming here

Recommend coming here

Recommend NOT coming here

Strongly recommend NOT coming here

3) People come to our program for many different reasons. Please tell us more about the help you may have received from our program.

1. Help meeting basic financial needs I got some or all of the help I wanted I wanted this help, but did not get it I did not want or need this help	2. Help with immigration concerns I got some or all of the help I wanted I wanted this help, but did not get it I did not want or need this help
3. Help finding safe and affordable housing I got some or all of the help I wanted I wanted this help, but did not get it I did not want or need this help	4. Help addressing my emotional needs I got some or all of the help I wanted I wanted this help, but did not get it I did not want or need this help
5. Help with the impact of the violence on my children (Please check one) I got some or all of the help I wanted I wanted this help, but did not get it I did not want or need this help	6. Help with the legal system/legal issues I got some or all of the help I wanted I wanted this help, but did not get it I did not want or need this help
7. Help with the impact of the violence on my relationships with family and friends I got some or all of the help I wanted I wanted this help, but did not get it I did not want or need this help	8. Help with transportation I got some or all of the help I wanted I wanted this help, but did not get it I did not want or need this help
9. Help accessing health care services I got some or all of the help I wanted I wanted this help, but did not get it I did not want or need this help	10. Help to make some of the changes in my life I got some or all of the help I wanted I wanted this help, but did not get it I did not want or need this help

4) Is there help you needed that is not included on the list of 10 items above? If yes, please explain.

5) Because of the services I have received from this program so far, I feel:

a.	I know more ways to plan for my safety
b.	I know more about community resources
c.	I know more about sexual and/or domestic violence and its impact
d.	I am more hopeful about my life

6) We try our best to make sure people feel welcomed and respected. Please tell us how we did.

1. Staff made me feel welcome
Strongly Agree
Agree
Disagree
Strongly Disagree
No Comment

2. Staff treated me with respect
Strongly Agree
Agree
Disagree
Strongly Disagree
No Comment

3. Staff respected my background and beliefs
Strongly Agree
Agree
Disagree
Strongly Disagree
No Comment

7) We try to respectfully meet the needs of different people (for example, needs related to: age, race, ethnicity, sexual orientation, gender, ability or disability, gender identity, educational background, economic status, etc). What do you think we could do better?

8) What do you think you would have done if these services did not exist?

9) Please describe any difficulties or concerns you have had with our services.

10) Please describe any positive experiences you have had with our services.

We ask the next few questions to see if different people have different experiences here. This can improve our services. Please skip any question that you worry may identify you.

1) I consider myslf to be a survivor of (please select one):
2) I consider myself to be (check all that apply):

African American/Black

Asian/Pacific Islander

Caucasian/White

Native American/Native Alaskan

Other

Hispanic/Latino(a)

3) My age is (please select one):
4) My gender is (please select one):
5) My sexual orientation is: (check one):
6) I am a person with a disability (check one):
7) I have minor children: