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

* 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

* 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?

* 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

* 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

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

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

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

* 9. What county do you live in?

* 10. Today's Date

Date / Time

T