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Advocacy Feedback Form

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Advocacy Feedback Form

For Survivors of Domestic Violence


Thank you in advance for taking the time to answer these questions. We know you are very busy right now, but we really appreciate your telling us what was helpful as well as unhelpful about our advocacy program. We take your comments seriously and are always trying to improve our services.


  1. My advocate helped me with issues in the following areas:

(please check all that apply)



            Legal Issues

            Education/ Training

            Employment Assistance

            Financial issues

            Physical/Mental Healthcare for myself

            Physical/Mental Healthcare for my children

            Issues regarding my children


            Social support


            Other (please explain: ________________________)


  1. For each statement below, please write the number that best reflects your experience.


0         NOT AT ALL

1         A LITTLE

2         SOMEWHAT

3         VERY MUCH




    1. The advocate I worked with was knowledgeable about community resources.
    2. The advocate was concerned about the needs of all of my family members.
    3. I decided what needs and issues I wanted to work on with my advocate.
    4. The advocate knew how to connect me to community resources.
    5. The advocate focused on my strengths.
    6. The advocate I worked with helped me learn new skills or practice existing skills.
    7. I felt supported and encouraged by my advocate.
    8. The advocate I worked with helped me define and meet the goals I thought were important.
    9. The advocate was nonjudgmental toward me.


  1. Because of my experiences in this program:


Not at all


A lot

Doesn’t apply to me: I didn’t need this

I feel more hopeful about the future.





I am more able to achieve goals I set for myself.





I know more about community resources I might need.





I have more ways to plan for my safety.





I feel less alone.





I know more about my options.






  1. What is your age?


___ 18-24 years old

___ 25-34 years old

___ 35-44 years old

___ 45-54 years old

___ 65+ years old

___ Prefer not to answer


  1. What term best describes your current gender identity?


___ Cisgender Woman                     ___ Cisgender Man

___ Transgender Woman                 ___ Transgender Man

___ Agender                                      ___ Genderqueer/Non-binary

___ Two Spirit                                               ___ Prefer not to answer

___ Another Identity (please specify): _______________


  1. I consider myself to be:


___ Straight                           ___ Gay/Lesbian/Queer

___ Bisexual                          ___ Another Identity (please specify): ______________

___ Prefer not to answer


  1. I am a person with (please check all that apply):


___ African American/Black ___ African

___ Asian                               ___ Asian American

___ Hispanic/Latinx              ___ Native Hawaiian/Pacific Islander

___ White/Caucasian                       ___ Native American/Alaska Native

___ Middle Eastern               ___ Another Identity (please specify): ______________

___ Prefer not to answer


  1. Any additional comments/suggestions or statements?





       Please check this box if you give us permission to share your comments on PR materials and/or funding reports. Again, this information will remain anonymous.




Thank you again for taking the time to fill this out – we will use your comments to continue to improve our services! And please contact us if you need anything.



From the Domestic Violence Evidence Project of the National Resource Center on Domestic Violence More evaluation tools and tips can be found at­‐tools/



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