* 1. 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 and very important to us. 
Please do this right away.  Please circle the number that best reflects your agreement or disagreement with the following statements.

  Strongly Disagree Disagree Neither Disagree Nor Agree Agree Strongly Agree N/A
Program staff treated me with respect.
Program staff were caring and supportive.
Program staff spent enough time talking about my safety.
Over all, my religious/spiritual beliefs were respected.
Over all, my sexual orientation was respected.
Over all, my racial/ethnic background was reespected.
Program staff helped address any needs related to my disability.
Program staff helped address any needs related to my youth or advancing age.

* 2. Evaluate the following statements.

  I got all of the help of this kind that I wanted I got some of the help of this kind that I wanted I wanted this kind of help, but I didn't get any this doesn't apply to me--I didn't want or need this
talking to someone who understands my situation
help figuring out how I can be safer
help keeping custody of my children
help with safe visitation for my children
help getting child support
help getting access to child care
help with child protection hearings or requirements
help with my children's school (e.g. records, changing schools, etc.)
help with health insurance for my children
help getting access to health care
help getting medical benefits (e.g. Medicaid)
help getting access to mental health services
help getting access to substance abuse services
help with government benefits (e.g. welfare/TANF, food stamps, others)
learning more about why/how domestic violence happens
help meeting my child's disability-related needs
help meeting my needs related to my disability
help with budgeting
help getting safe & adequate housing
help getting job-related training
help getting a job
information about counseling options
support to make some changes in my life
help with a protective order
information about the legal system process
someone to go to court with me
information about my legal rights and options
help supporting the court case against the person who abused me
help stopping the court case against the person who abused me
help with probation issues
help getting access to an attorney
help with police issues
help preparing to testify in court
help dealing with my arrest
help dealing with sexual abuse services for me or my children
help understanding my rights & options related to my residency status
help getting benefits as an immigrant
help getting residency status
help getting support from my faith community
help arranging transportation to meet my needs
help ending my relationship
help staying in my relationship safely
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