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Client service evaluation form

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You, as 'service users', are the experts in terms of what kinds of service best meets your needs. Filling out this form will help us shape our service provision in the most effective way possible. Your opinions are important and will be treated with confidentiality and respect. There is no identifying information on this form. Note: Non-identifying information from this survey may be quoted, summarised and published.
1. Your gender	Female Male
2. Your age group	0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56+
3. Are you:	A survivor of recent rape or sexual assault (within the last month) A survivor of rape or sexual assault within the last 5 years A survivor of rape or sexual assault longer than 5 years ago A survivor of childhood sexual assault/Incest (when you were under 18 years old) A parent/caregiver of a child who has been sexually assaulted A parent/caregiver of an adult who has been sexually assaulted A partner of a person who has been sexually assaulted None of the above
4.1 How did you hear about this service?	Newspaper Pamphlet Telephone book Poster/sticker Internet Word of mouth Police Doctor Other service provider Other
4.2 Other - please specify
5.1 Have you ever attended a sexual assault counselling service before?	Yes No
5.2 If YES, where?
6.1 With regards to SECASA, which location did you attend?	Crisis care unit - MMC Child protection unit - MMC Legal service Moorabin Dandenong - VISY Dandenong - CHC Pakenham Cranbourne Frankston Rosebud YSTOP PCV WINJA Galiamble QEC Other
6.2 Other - please specify
7 What year did you attend?
8.1 Was the centre easy to access in terms of transport?	Yes No
8.2 Was the centre easy to find?	Yes No
8.3 Was physical access to the centre easy?	Yes No
9.1 Did you feel safe/comfortable in the agency?	Yes No
9.2 What could be improved?
10. Did you attend for:	Individual counselling A group program Workshop (Therapeutic) Workshop (Information)
11. Who was your counsellor/group facilitator(s)?
12. How many sessions did you attend over what period of time?
13.1 Have your ideas/beliefs/feelings about sexual assault changed since attending this centre?	Yes No
13.2 If yes, how?
14. What effect do you expect these changes to have on your future?
15. Was there anything you particularly liked about the sessions and the service?
16. Was there anything you particularly disliked about the sessions and the service?
The next set of questions relate to how you percieved your counsellor/group facilitator(s). Remember, to be as frank as possible with your feedback is important. Counsellors can be described in terms of variuos characteristics. Below are listed 7 possible counsellor characteristics. For each of these, please indicate the extent to which YOU percieved the counsellor as demonstrating these characteristics.
17.1 Friendly	Not at all 1 Somewhat 2 3 4 5 Extremely
17.2 Any comments
18.1 Caring	Not at all 1 Somewhat 2 3 4 5 Extremely
18.2 Any comments
19.1 Accepting	Not at all 1 Somewhat 2 3 4 5 Extremely
19.2 Any comments
20.1 Competent	Not at all 1 Somewhat 2 3 4 5 Extremely
20.2 Any comments
21.1 Supportive	Not at all 1 Somewhat 2 3 4 5 Extremely
21.2 Any comments
22.1 Understanding	Not at all 1 Somewhat 2 3 4 5 Extremely
22.2 Any comments
23.1 Professional	Not at all 1 Somewhat 2 3 4 5 Extremely
23.2 Any comments
24. Any additional comments?
25. Do you have a clearer understanding of the issues discussed?	Yes No
26. Do you feel better able to manage the problems or issues discussed?	Yes No
27. Do you feel that counselling/the workshop or group was a positive experience?	Yes No
28. Are there any comments you would like to provide to help us in our service provision?
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Thank you - your assistance is appreciated

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The South Eastern Centre Against Sexual Assault acknowledges the traditional Aboriginal owners of country throughout Victoria. We pay our respects to them, their culture and their Elders past, present and future.