Counseling Feedback Form Updated

Counseling Feedback Form

Thank you for your help! Although doing this is voluntary, your answers to these questions will help our program understand and improve the services we provide. We do not ask for your name. your answers are confidential are very important us. Please respond honestly. When you have finished, put this form in the envelope you were given, seal it, and put it in the place the staff member showed you.

1. About how many sessions with program staff for counseling have you had in the last year?

­­___ 0              ­­___ 1              ___ 2-5           ___ 6-10         ___ more than 10

2. Have you filled out one of these forms about your experience with counseling in the past?

___ No                       ___ Yes           If yes:  About how long ago?            _______ months

3. People want to talk to counselor for different reasons. The following list describes reasons why you may have come to our program for counseling. Every woman wants and needs different things, so there are no “right” answers. Please use one of the numbers in the box below to rate each of the items on the list according to the help you received from counseling:

3 = I got all of the help of this kind that I wanted

2 = I got some of the help of this kind that I wanted

1 = I wanted this kind of help, but I didn’t get any

• = It doesn’t apply to me – I don’t want or need this

4. I am most comfortable talking about my issues and concerns related to the abuse I have experienced in the following way (please check only one):

­___ In a support group with other women who have had a similar experiences

___ In a conversation with only one other person

___ I am equally comfortable talking in a group or with just one person

5. Because of the counseling services I have received from this program so far, I feel (please check yes or no:)

Yes   No                                                                                   Yes   No

___  ­­­___  I know more ways to plan for my safety         ___   ___ More hopeful about the future

___  ___  I know more about community resources      ___   ___ More comfortable asking for help

       ___  ___  Like I can do more things on my own              ___   ___ More comfortable in my decision-making

6. Please circle the number that best reflects your agreement or disagreement with the following statements.

7. Overall, thinking about my experiences with counseling, I would rate the help I have received so far as:

___ Very helpful        ___ Helpful    ___ A little helpful    ___ Not at all helpful

Comments: ­­­­­­_____________________________________________________________

_______________________________________________________________________

8. If a friend of mine told me she was thinking of coming to this program for help, I would:

___ Strongly recommend she come            ___ Recommend she come

___ Recommend she not come                   ___ Strongly recommend she not come

Because: __________________­­­­­­­­­­­­­­­­­____________________________________________

9. I consider myself to be:

___ African American/Black                         ___ Asian

___ African                                                    ___ Asian American

___ Native American/Alaska Native            ___ Hispanic/Latinx

___ Middle Eastern                                      ___ Native Hawaiian/Pacific Islander

___ Multiracial                                              ___ White/Caucasian

___ Prefer not to answer                             ___ Another identity (please specify): ­­­­_____

If there is a particular ethnic background that is important to you, please identify:­­­ _____

10. My age is:

___ 18-24   ___ 25-34   ___ 34-44   ___ 44-54   ___ 55-64   ___ 65+  ___ Prefer not to answer

11. I am:

___ Cisgender woman                ___ Cisgender man

___ Transgender woman                        ___ Transgender man

___ Genderqueer/Non-Binary   ___ Agender

___            Two-spirit                             ___ Another Identity (please specify): ___________

___ Prefer not to answer

12. I have ________ minor children (age 17 or younger)

13. I consider myself to be

___ Straight   ___ Bisexual   ___ Gay/Lesbian/Queer   ___ Prefer not to answer

___ Another (please specify): ­­­­­­­_________________

14. The highest level of education I have so far is:

___8^th grade or less

___ 9^th-11^th grade

___ High school graduate or GED

___ Some college

___ College graduate

___ Advanced degree

Thank you very much

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