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Parenting Support Group Evaluation Form

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Support Group Evaluation Form
for Survivors of Sexual Assault/Abuse

This is an anonymous questionnaire. Please do not put your name on it. We value your feedback, and the answers you provide will be used to improve the services we provide. Thank you in advance for taking the time to answer to the following questions.

1. I attended the following number of group sessions (please check one):

___ 1-2 sessions
___ 3-5 sessions
___ 6-10 sessions
___ More than 10 sessions

2. Please check the line under the response that best matches how you feel:
Very Much Some A Not
The groups facilitator/s would offer information about /A Lot what little at All
community resources I might need now or in the future. ___ ___ ___ ___
I feel emotionally supported by the group facilitators. ___ ___ ___ ___
I feel more in control of my life than I did before starting the
group. ___ ___ ___ ___
I know more ways to plan for my safety. ___ ___ ___ ___
I know more about community resources I might need. ___ ___ ___ ___
I found your counseling services to be helpful to my healing
process. ___ ___ ___ ___
I have a better understanding of common reactions to sexual
violence. ___ ___ ___ ___

3. If a friend of mine told me that they were thinking of using your group services, I would:

___ Strongly recommend that they contact you
___ Suggest that they contact you
___ Suggest that they NOT contact you
___ Strongly recommend that they NOT contact you
Because: ¬¬¬¬___________________________________________________________

___________________________________________________________________

4. 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

5. 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): _______________

6. I consider myself to be:

___ Straight ___ Gay/Lesbian/Queer
___ Bisexual ___ Another Identity (please specify): ______________
___ Prefer not to answer

7. 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

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

___ A physical disability
___ A hearing disability
___ A visual disability
___ A cognitive disability
___ An emotional/psychiatric disability
___ An alcohol/chemical disability
___ A learning/developmental disability
___ No disability
___ Other disability

9. 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 should 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 http://www.dvevidenceproject.org/evaluation-­‐tools/

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