SAFETY ALERT: If you are in danger, please use a safer computer and consider calling 911. The National Domestic Violence Hotline at 1-800-799-7233 / TTY 1-800-787-3224 or the StrongHearts Native Helpline at 1−844-762-8483 (call or text) are available to assist you. Please review these safety tips.

Individual Counseling Evaluation Form

Share this resource:

Individual Counseling 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 the following questions.  

 

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

 

___ 1-8 sessions  

___ 8-16 sessions  

___ 16-24 sessions 

___ 24-32 sessions

___ More than 40 sessions 

 

  1. Please check the LINE under the response that best matches how you feel: 

     Very     Some     A      Not

The counselor would offer information about community resources    /A lot   what   little   at All

 I might need now or in the future.                                                                  ___       ___           ___     ___

I feel more in control of my life than I did before starting the

counseling.                                                                                             ___       ___               ___          ___

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.                                                                                                 ___                    ___      ___     ___

 

  1. When I think about what I wanted to get out of counseling, I would say (please check one):

 

___ It has met all or exceeded all of my expectations  

___ It has met more of my expectations  

___ It has met some of my expectations  

___ It has met few or none of my exceptions  

 

Comments: ________________________________________________________

 

__________________________________________________________________

 

  1. If a friend of mine told me that they were thinking of using your 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: ____________________________________________________________

 

____________________________________________________________________

 

  1. Thinking about how long you had to wait to get your first appointment, are you: 

___ Satisfied with the amount of time it took  

___ Not satisfied with the amount of time it took  

 

Because: ________________________________________________________

 

________________________________________________________________

 

  1. The times that I have been able to schedule an appointment: 

 

___ Met my needs                            ___ Did not meet my needs  

 

Because: ________________________________________________________

 

_____________________________________________________________­­­­­___

 

  1. In thinking about how you are treated by turning point staff, do you feel that you are: 

 

___ Completely respected               ___ Somewhat respected  

___ Somewhat disrespected            ___ Completely disrespected  

 

Because: ________________________________________________________

 

_____________________________________________________________­­­­­___

 

  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. 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 

 

  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 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-­‐

More to explore