Client Survey
Please select "yes" or "no" below for services you have received in the past 90 days.
Date
-
Month
-
Day
Year
Date
Safehouse
If you did NOT receive Safehouse Services, please skip to the next section.
1. I know more about Community Resources.
Yes
No
2. I know more ways to plan for my safety.
Yes
No
3. I feel more self-sufficient as a result of this program
Yes
No
4. I feel more informed of my rights as a result of this program.
Yes
No
Legal
If you did NOT receive Legal Services, please skip to the next section.
1. I know more about Community Resources.
Yes
No
2. I know more ways to plan for my safety.
Yes
No
3. I feel more self-sufficient as a result of this program.
Yes
No
4. I feel more informed of my rights as a result of this program.
Yes
No
Support Groups
If you did NOT participate in Support Groups, please skip to the next section.
1. I know more about Community Resources.
Yes
No
2. I know more ways to plan for my safety.
Yes
No
3. I feel more self-sufficient as a result of this program.
Yes
No
4. I feel more informed of my rights as a result of this program.
Yes
No
Counseling
If you did NOT receive Counseling Services, please skip to the next section.
1. I know more about Community Resources.
Yes
No
2. I know more ways to plan for my safety.
Yes
No
3. I feel more self-sufficient as a result of this program.
Yes
No
4. I feel more informed of my rights as a result of this program.
Yes
No
Client Services/24-Hour Helpline
If you did NOT receive Client Services/24-Hour Helpline Services, please skip.
1. I know more about Community Resources.
Yes
No
2. I know more ways to plan for my safety.
Yes
No
3. I feel more self-sufficient as a result of this program.
Yes
No
4. I feel more informed of my rights as a result of this program.
Yes
No
Comments:
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