CPS Outreach Evaluation Form

Please take a moment to evaluate the program/presentation you attended. Your feedback is important to us.

Please do not enter private health information in this anonymous survey; instead use the eTang patient portal (https://etang.berkeley.edu/) to discuss counseling or treatment issues with a healthcare provider or insurance specialist."

* 1. What's the date of the program that you are attending?

* 2. Please select the outreach event that you are evaluating:

* 3. If you marked "other," what is the name of the outreach program that you attended?

* 4. Please indicate the name(s) of the facilitator:

* 5. Are you an:

* 6. Are you in the 1st generation in your family to attend college?

* 7. Are you an international student?

* 8. Gender:

* 9. Ethnicity (Check all that apply):

* 10. How effective was this program in:

  Very Effective Mostly Effective Somewhat Effective Mostly Ineffective Very Ineffective N/A
Providing information that was relevant to you?
Offering new skills that you can use in your daily life?
Increasing your understanding of mental health issues
Increasing your awareness of UC Berkeley Counseling and Psychological Services
Demonstrating sensitivity to multicultural differences?
Increasing your comfort in seeking counseling for yourself during times of need?
Increasing your comfort in referring others (students) to counseling during their times of need?

* 11. Please rate your overall satisfaction with:

  Extremely Satisfied Satisfied Somewhat Satisfied Somewhat Dissatisfied Dissatisfied Extremely Dissatisfied
The Program:
The Presenter:

* 12. Any suggestions for improving this program and/or suggestions for other topics?

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