Client Survey Step 1 of 4 25% Section AStrongly disagreeSomewhat DisagreeNeutralSomewhat AgreeStrongly agreeStaff respected my background (e.g. gender, race, culture, ethnicity, sexual orientation, disability, lifestyle, etc.).Services were available at times that were good for me.I was asked to participate in deciding what services I would receive.I feel the staff heard me.I got the kind of service I wanted.Staff helped me believe that I could change and improve my life.The services I received helped me deal more effectively with my problems.Because of the services I received, I learned skills to help me better manage my life.The services I received helped me identify a support system.The services I received helped me become aware of how crisis and trauma affect my life.The services I received helped me plan for my safety.The staff informed me about Victims Rights.The services I received helped me cope with my fear for my safety.Because of the services I received, I know more about the options and choices available to me overall.I would return to this agency if I needed victim services in the future.I would recommend this agency to a friend in need of victim services.In an overall, general sense, I am satisfied with the services I received.Because of the services I received, I know about community resources that are available to me.UntitledIs there anything else you would like to say? Section BIf you visited our facility, please answer the following questions. If you never visited our facility, skip to section C.Strongly disagreeSomewhat DisagreeNeutralSomewhat AgreeStrongly agreeI was able to get around the building easily.The facilities were comfortable for me.UntitledIs there anything else you would like to say? Section CIf someone from our agency met you at an emergency medical facility, please answer the following questions about the services we provided. If not, please skip to Section D.Strongly disagreeSomewhat DisagreeNeutralSomewhat AgreeStrongly agreeI felt supported through the medical system by staff from the agency.Because of the services I received, I know about the medical system.UntitledIs there anything else you would like to say? Section DIf someone from our agency accompanied you through the legal process, please answer the following questions about the services we provided. If not, please skip to Section E.Strongly disagreeSomewhat DisagreeNeutralSomewhat AgreeStrongly agreeI felt supported through the legal system by staff from the agency.Because of the services I received, I know about the legal system.UntitledIs there anything else you would like to say? Section EIf you had any of these out-of-pocket (not covered by any type of insurance) financial losses as a direct result of the victimization, please answer the following questions. If you did not have any of these out-of-pocket financial losses, please skip to Section F. • Medical Expenses • Home healthcare • Counseling fees • Loss of earnings • Loss of support • Funeral Expenses • Crime scene cleanup fees • Relocation expenses • Transportation expenses • Child care • Replacement of medical devices • Replacement services (of normal daily household chores-cooking, lawn care, cleaning, etc.)Strongly disagreeSomewhat DisagreeNeutralSomewhat AgreeStrongly agreeThe agency made me aware of the Pennsylvania Victim Compensation Program.The information provided by the agency helped me understand the victim compensation process.UntitledIs there anything else you would like to say? Section FPlease consider the following reactions which sometimes occur after a traumatic event. This section is concerned with your personal reactions to the traumatic event which happened to you. Please select one answer for each question.Not at AllA Little BitModeratelyQuite a LotVery MuchHow much have you been bothered by unwanted memories, nightmares, or reminders of the event?How much effort have you made to avoid thinking or talking about the event, or doing things which remind you of what happened?To what extent have you lost enjoyment for things, felt sad or depressed, kept your distance from people, or found it difficult to experience feelings?How much have you been bothered by poor sleep, poor concentration, jumpiness, irritability or feeling watchful around you?How much have you been bothered by pain, aches or tiredness?How much would you get angry or upset when stressful events or setbacks happened to you?How much have you been blaming yourself or feeling guilty for what happened to you?How much have the above symptoms interfered with your ability to work or carry out daily activities?How much have the above symptoms interfered with your relationships with family or friends?How much better do you feel since beginning services? (as a percentage)100% (As well as could be)90%80%70%60%50%40%30%20%10%0% (No change)Overall, how much have the above symptoms improved since starting services?Very MuchMuchMinimallyNo ChangeWorseUntitledWhat did you find helpful about our services?UntitledWhat did you find not helpful about our services? Please include any suggestions you have for improvement. Client DemographicsEthnic Origin Black/African-American White Hispanic/Latino(a) Asian or Pacific Islander Bi-racial Unknown Marital/Relation (If Adult) Married Living with Partner Separated Relationship, Not Living with Partner Divorced Single Widow/Widower Education No GED or High School GED High School Some College College Degree Some Graduate School Graduate Degree Post Graduate Unknown Household Income (Annually) Less than $5,000 $5,000 - $9,999 $10,000 - $14,999 $15,000 - $19,999 $20,000 - $24,999 $25,000 - $29,999 $30,000 - $49,999 $50,000 or more Unknown Primary Income Source Employment Pension/Retirement Support Social Security Unemployment Public Assistance Other Gender Male Female Other Date of Birth MM slash DD slash YYYY Type of VictimizationCheck all that apply to your current situation Domestic Violence Sexual Assault Child Abuse (Sexual) DUI Victim Caregiver of Victim/Survivor Physical Assault Child Abuse (Physical) Robbery Homicide Survivor Adult Offender (Over 18 years of age) Juvenile Offender (Under 18 years of age How long did you receive services from our agency? 0-3 months 3-6 months 6-12 months 1-2 years Type of Service ReceivedCheck all that apply. Crisis Counseling Victim Compensation Legal Advocacy Shelter Group Counseling Individual Therapy Medical Advocacy Have you had prior victimizations? Yes No If you have had prior victimizations, please list the types.Mental Health Statistics Improvement Program (2000). Mental Health Statistics Improvement Program Survey. Retrieved online [http://www.mhsip.org/surveylink.htm]Oct 16, 2007. Connor, K., & Davidson, J. (2001). SPRINT: A brief global assessment of post-traumatic stress disorder. International Clinical Psychopharmacology, 16, 279-284. Δ
