My advocate helped me with issues in the following areas (check all that apply)

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* 1. My advocate helped me with issues in the following areas (check all that apply)

Please describe your experience working with your advocate. For each statement below, please indicate the rating that best describes your experience.

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* 2. Please describe your experience working with your advocate. For each statement below, please indicate the rating that best describes your experience.

  Not at all A Little Somewhat Very Much
I was listened to and treated respectfully
The advocate I worked with was knowledgeable about community resources
The advocate was concerned about the needs of all my family members
I decided what needs and issues I wanted to work on with my advocate
The advocate knew how to connect me to community resources  
The advocate focused on my strengths
I felt supported and encouraged by my advocate
The advocate I worked with helped me define and meet the goals I thought were important
The advocate was nonjudgmental toward me
The advocate I worked with helped me learn new skills or practice existing skills
Please tell us more about your experience working with the advocate. What did you appreciate most? What recommendations do you have to improve services?

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* 3. Please tell us more about your experience working with the advocate. What did you appreciate most? What recommendations do you have to improve services?

Please describe your experience with the services provided by Rivers of Hope. For each statement below, please choose the rating that best reflects your experience.

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* 4. Please describe your experience with the services provided by Rivers of Hope. For each statement below, please choose the rating that best reflects your experience.

  Not at All A Little Somewhat Very Much N/A
I have a safety plan for me (and my children)
I have a support system I can contact when I need help
I have effective coping skills to deal with the effects of violence
I have healthy and positive relationships in my life
I am confident that I can make healthy decisions for me (and my children)
I feel supported by the systems in the community to help me
I feel I am in control of my life and my choices
I feel positive about my life and future
I would recommend Rivers of Hope to others
Because of my experiences with Rivers of Hope: 

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* 5. Because of my experiences with Rivers of Hope: 

  Not at All A Little Somewhat Very Much N/A
I feel more hopeful about the future
I am more able to achieve goals I set for myself
I have more ways to plan for my safety
I feel less alone
I know more about my options
Comments (what worked well, what could have been better about your experience? Feel free to offer suggestions)

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* 6. Comments (what worked well, what could have been better about your experience? Feel free to offer suggestions)

Approximate date you started working with us (month/year)

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* 7. Approximate date you started working with us (month/year)

Approximate date you last worked with us (month/year)

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* 8. Approximate date you last worked with us (month/year)

What county do you live in?

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* 9. What county do you live in?

Today's Date

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* 10. Today's Date

Date / Time

T