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.

Support Group Evaluation Form

Share this resource:

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 

 

  1. 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.                                                                                       ___                      ___            ___      ___

 

  1. 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: ­­­­___________________________________________________________

 

___________________________________________________________________

 

  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-­‐tools/

More to explore