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Support Services and Advocacy Feedback Form Updated

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Support Services & Advocacy Feedback Form


Thank you for your help. Your answers to these questions will help us improve our services. Please answer honestly – there are no right or wrong answers. Your answers are confidential are very important us. Please complete this right away. When you have finished, please put this form in the envelope you were given, seal it, and put it in the confidential place the advocate showed you.


  1. People attend support groups for different reasons. The following list describes reasons why you may have come to our program for a support group. 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 our program’s support group:


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


       talking to someone who understands my situation

       information about counseling options

       help figuring out how I can be safer

       support to make some changes in my life

       help keeping custody of my children

       help with a protective order

       help with safe visitation for my children

       information about the legal system process

       help getting child support

       someone to go with me to court

       help getting access to child care

       information about my legal rights and options

       help with child protection hearings or requirements

       help supporting the court case against the person who abused me

       help with my children’s school (e.g. records, changing schools, etc.)

       help stopping the court case against the person who abused me

       help with health insurance for my children

       help with probation issues

       help getting access to health care

       help getting access to an attorney

       help getting medical benefits (e.g. Medicaid)

       help with police issues

       help getting access to mental health services

       help preparing to testify in court

       help getting access to substance abuse services

       help dealing with my arrest

       help with government benefits (e.g. welfare/ TANF, food stamps, others)

       help dealing with sexual abuse services for me or my children

       learning more about why/how domestic violence happens

       help understanding my rights & options related to my residency status

       help meeting my child’s disability-related needs

       help getting benefits as an immigrant

       help meeting my needs related to my disability

       help getting residency status

       help with budgeting

       help getting support from my faith community

       help getting safe & adequate housing

       help arranging transportation to meet my needs

       help getting job-related training

       help ending my relationship

       help getting a job

       help staying in my relationship safely


        other (describe): _________________________________


  1. Our advocacy and support services are meant to help you to get what you need and to have your voice heard. About how many advocacy/support-related contacts with program staff have you had in the last year (your best guess)?


___ One          ___ Two          ___ Three-ten          ___ More than ten       ___ None


  1. Have you been a resident during any part of this time? ___ Yes ___ No


  1. Have you completed this form before, during the past year? ___ Yes ___ No


___ I don’t remember


  1. Because of attending this support group, 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

       ___   ___  I know more about my rights and options        ___   ___ More confident in my decision-making

       ___   ___ That I will achieve the goals I set for myself      ___   ___ Like I can do more things on my own


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




doesn’t apply

strongly disagree



strongly agree



Program staff treated me with respect.








Program staff were caring and supportive.








Program staff spent enough time talking about my safety








Over all, my religious/spiritual beliefs were respected.








Over all, my sexual orientation was respected.








Over all, my racial/ethnic background was respected.








Program staff helped address any needs related to my disability








Program staff helped address any needs related to my

youth or advancing age









  1. Is there anything the program could do to improve our advocacy/support services?

___ Yes           ___ No


If yes: please describe: ____________________________________________________


  1. Overall, thinking about my experiences with support groups, I would rate the help I have received so far 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 to this program for help, I would: (please check one)


___ Strongly recommend she come            ___ Recommend she come

___ Recommend she not come                   ___ Strongly recommend she not come


Because: ­ __­­­­­­_____________________________________________________________








  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)


  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!

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