Support Services and Advocacy Feedback Form Updated

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

        other (describe): _________________________________

2. 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

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

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

___ I don’t remember

5. Because of attending this support group, I feel (please check yes or no):

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

___ Yes           ___ No

If yes: please describe: ____________________________________________________

8. 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: ­­­­­­_____________________________________________________________

9. 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: ­ __­­­­­­_____________________________________________________________

10. 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:­­­ _____

11. My age is:

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

12. I am:

___ Cisgender woman                      ___ Cisgender man

___ Transgender woman                  ___ Transgender man

___ Genderqueer/Non-Binary         ___ Agender

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

___ Prefer not to answer

13. I have ________ minor children (age 17 or younger)

14. I consider myself to be

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

___ Another (please specify): ­­­­­­­_________________

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

___8^th grade or less

___ 9^th-11^th grade

___ High school graduate or GED

___ Some college

___ College graduate

___ Advanced degree

Thank you very much!