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.

Shelter Resident Exit Survey Updated

Share this resource:

Shelter Resident Exit Survey

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. Approximate number of days you stayed in this shelter this stay: _______________

___  ___  ___  ___      (Write in the first 2 letters of your mother’s first name, and the first 2 numbers of your most recent address, e.g., WE17. No one will be able to connect this information with you, but it will allow us to better meet resident’s needs. If you still do not feel comfortable with this, please use two letters followed by two numbers that you will remember and can use again later. If you filled out the Intake survey (survey #1). Please use the same letters and numbers you used then.

  1. The following list describes different types of services you may have wanted and may have received while you were in the shelter. Every woman wants and needs different things, so there are no “right” answers. Please rate each of the items on the list according to the help you received with:
 
  We ask the next questions to see if different
women have different experiences here, so we can continue to improve our
services for ALL women. But please leave any blank if you are concerned it 

___ safety for myself                                                                 ___ transportation

___ safety for my children                                                        ___ support from other women

___ learning about my options and choices                         ___ a job or job training

___ paying attention to my own wants and needs             ___ counseling for myself

___ paying attention to my children’s wants

        and needs                                                                             ___ counseling for my children

___ understanding about domestic violence                        ___ emotional support for myself

___ safety planning                                                                    ___ health issues for myself

___ education/school for myself                                            ___ health issues for my children

___ education/school for my children                                   ___ my abuse-related injuries

___ reconnecting with my community                                   ___ leaving my relationship

___ budgeting & handling my money                                     ___ TANF (welfare) benefits

___ child protection system issues                                         ___ other government benefits

___ child welfare system issues                                              ___ legal system/legal issues     

___ protective/restraining order                                            ___ my abuser’s arrest

___ my own arrest                                                                     ___ custody or visitation questions

___ divorce-related issues                                                        ___ immigration issues

___ ideas for handling the stress in my life                           ___ childcare

___ connections to other people who can help me            ___ finding housing I can afford

___ responding to my children when they are upset

        or causing trouble                                                              ___ other (what?): __________

  1. What about the shelter has made you feel the most comfortable? _______________

_____________________________________________________________________

  1. Because of my experience in the shelter, 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

___   ___ more confident in my decision-making                    ___  
___ I know more about my 

 

Comments: ____________________________________________________________

______________________________________________________________________

  1. Because of our time in the shelter, I think my children (check yes or no, or check “doesn’t apply – no children”):
 
 

 Yes   No                                                                   
                               Yes   No

___   ­­­___ are better able to express their
feelings without violence                
   ___  
___ feel more supported

___   ___                    have
more understanding of what has been happening at home       ___   ___ doesn’t apply – no children

Comments: ____________________________________________________________

______________________________________________________________________

  1. Please circle the number that best reflects your agreement of disagreement with the following statements:
 

doesn’t apply

strongly disagree

disagree

agree

strongly agree

Shelter staff treated me with respect.

0

1

2

3

4

Shelter staff were caring and supportive.

0

1

2

3

4

Shelter staff spent enough time talking about my safety

0

1

2

3

4

Shelter staff spent enough time talking about my children’s safety

0

1

2

3

4

Over all, my religious/spiritual beliefs were respected.

0

1

2

3

4

Over all, my sexual orientation was respected.

0

1

2

3

4

Over all, my racial/ethnic background was respected.

0

1

2

3

4

Shelter staff helped address any needs related to my disability

0

1

2

3

4

Shelter staff helped address any needs related to my youth or advancing age

0

1

2

3

4

  1. Overall, thinking about my stay here, I would rate the help I received at this shelter as:

___ Very helpful        ___ Helpful    ___ A little helpful    ___Not at all helpful

Comments: ____________________________________________________________

______________________________________________________________________

  1. If a friend of mine told me she was thinking of coming her for help, I would: (please check one):

___ Strongly recommend she come            ___ Recommend she come

___ Recommend she not come                   ___ Strongly recommend she not come

Comments: ____________________________________________________________

______________________________________________________________________

  1. The shelter staff try to make your stay as helpful as possible. However, every woman’s situation is different, and sometimes problems can occur, even in the best of programs. The list describes different types of problems you may have experienced while you were in the shelter. Please let us know about any problems you experienced, using the numbered ratings for each item on the list. Please be honest and add your comments!

Please put one of these numbers on the space next to each type of problem listed below:

 3 = This was not a
problem for me                           1
= This was a problem, and it was not resolved to my satisfaction

  1. Problems related to rules about – Comments

___ Curfew                                                                   __________________________________           

___ Childcare (what?)                                                 __________________________________           

___ Child discipline and monitoring                          __________________________________           

___ Chores                                                                     __________________________________           

___ Time limits on staying here                                __________________________________           

___ Going to my job or school                                   __________________________________           

___ Telephone privileges                                            __________________________________           

___ Contact with my abusive partner                     __________________________________           

___ Contact with family or friends                           __________________________________           

___ Allowing teen boys to stay here                        __________________________________           

___ Other (what?): ________________                 __________________________________           

  1. Problems related to other concerns –

___ Conflict with other women in shelter               __________________________________           

___ Conflict with staff                                                 __________________________________           

___ Lack of respect for my customs/practices     __________________________________           

___ Choices of food available                                    __________________________________           

___ Need for transportation                                       __________________________________           

___ Communicating (e.g. language barriers)           __________________________________           

___ Difficulties getting around in the shelter          __________________________________           

___ Finding privacy                                                        __________________________________           

___ Other (what?): _________________                 __________________________________           

We ask the next questions to see if different
women have different experiences here, so we can continue to improve our
services for ALL women. But please leave any blank if you are concerned it 

  1. 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:­­­ _____

  1. My age is:

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

  1. I am:

___ Cisgender woman                ___ Cisgender man

___ Transgender woman                        ___ Transgender man

___ Genderqueer/Non-Binary   ___ Agender

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

___ Prefer not to answer

  1. I have ________ minor children (age 17 or younger)
  2. How many are with you here? ________ (# of children)
  1. I consider myself to be

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

___ Another (please specify): ­­­­­­­_________________

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

___8th grade or less

___ 9th-11th grade

___ High school graduate or GED

___ Some college

___ College graduate

___ Advanced degree

Thank you very much!!

More to explore