Add Communty-Based Services Feedback Survey Record

Date Received: (Select)Data Entered By
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 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
6. 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
7. 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
8. 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

4) Because of the services received from this program so far:

a.I know more ways to plan for my safety Yes No
b.I know more about community resources Yes No
c.I know more about sexual and/or domestic violence and its impact Yes No
d.I am more hopeful about my life Yes No
e.I know how to take my next steps Yes No
f.I feel that my children know that it's okay to talk about their experiences with violence Yes No
g.I feel that my children are having more positive interactions with others Yes No
h.Staff made me feel that I could accept or decline services offered to me Yes No

5) 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

If you did not feel welcomed, please tell us about your concerns:
2. Staff treated me with respect
Strongly Agree
Agree
Disagree
Strongly Disagree
No Comment

If you did not feel respected, please tell us about your concerns:
3. Staff respected my background and beliefs
Strongly Agree
Agree
Disagree
Strongly Disagree
No Comment

If you did not feel your background and beliefs were respected, please tell us about your concerns:

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

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

8) 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): No Response Domestic Violence Sexual Violence Both Sexual and Domestic Violence
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): No Response Under 30 30-39 40-49 50-59 60 and over
4) My gender is (please select one): No Response Female Male Transgender
5) My sexual orientation is: (check one): No Response Heterosexual/Straight Gay/Lesbian/Bisexual/Queer Other
6) I am a person with a disability (check one): No Response Yes No
7) I have minor children: No Response Yes No