Client Exit Evaluation

JACKSON-BIBBY AWARENESS GROUP

CLIENT EXIT EVALUATION
Looking back over the time spent in this program, will you please state in your own words, what your participation has meant to you. No two people have the same experience, and each of you has made unique contributions to the program. Your honest comments will be of value in improving the quality of our program.
Comments:*
Please indicate which of the following ways of communication you found the most beneficial.

(Please indicate by 1 = most and 5 = least, etc.)
Lectures*
( 1 = most and 5 = least )
Films*
( 1 = most and 5 = least )
Group*
( 1 = most and 5 = least )
Staff Members*
( 1 = most and 5 = least )
Other Clients*
( 1 = most and 5 = least )
In the time, during the program, have you found new ways to improve your life?

Examples: hobbies, recreation, improved relationships, job performance, etc.
Please Comment*
Do you feel the information you have received here has changed your attitude about drinking and driving?*

YesNo
Do you feel it has changed your attitude about drinking in general?*

YesNo
In what way?*
If you plan to return to your previous drinking pattern, what do your intend to do to avoid drinking and driving?
Please comment:*
Should alcohol create further problems for you in the future, would you consider returning to a self-help meeting, for example Alcoholics Anonymous? *

YesNo
Please comment:*
Client Name*
Date*

MonthDayYear
Date
Location*
Email*
example@example.com
On submitting the form, the form(s) will be emailed directly to Jackson-Bibby.
Should be Empty:

JACKSON-BIBBY AWARENESS GROUP

Please indicate which of the following ways of communication you found the most beneficial.