FEEDBACK FORM


    This anonymous form will help community leaders learn about needs in our community, and about how well the crisis counselors/outreach workers are meeting these needs. Please do not put your name on this form. If you filled out a form like this in the past week, please do not fill in this one. We thank you very much for your time!

    How good of a job did the counselor or outreach worker do…

    (From one to five; one being extremely poor and five being excellent.)


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    Please indicate below which program services you have used. If you have used the service, please indicate whether or not it was helpful to you.

    One-to-one interaction (with counselor/outreach worker):


    YesNo


    YesNo

    Public education presentation:


    YesNo


    YesNo

    Group counseling/support group:


    YesNo


    YesNo

    Handouts/materials:


    YesNo


    YesNo

    Internet sites (Crisis Counseling Assistance and Training Program [CCP] website, Facebook, etc.):


    YesNo


    YesNo

    Referral resources:


    YesNo


    YesNo

    Other (please specify):


    YesNo


    YesNo


    If you have used referral resources, which type(s) did you utilize?


    How good of a job did this program do with…

    (From one to five; one being extremely poor and five being excellent.)


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    In general


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    (From one to five; one being not at all useful and five being extremely useful.)


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    People experience disasters in a variety of ways. Below is a list of experiences you may have had. Please select all that apply to you.

    For the questions below, please share your reactions (feelings, emotions, and thoughts) about the disaster, considering your reactions in THE PAST MONTH. Using a scale of 1 to 5, where 1 is not at all, 2 is a little bit, 3 is somewhat, 4 is quite a bit, and 5 is very much, in the past month to what extent have you…


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    Comparing your emotional and mental well-being before the disaster to now, do you feel better, worse, or about the same?

    Feel better nowFeel about the sameFeel worse now

    Comparing how well you take care of your health before the disaster to now, do you take care of your health better, worse, or about the same?

    Take care of your health better nowTake care of your health about the same nowTake care of your health worse now

    Comparing how well you work (including a job, schoolwork, and housework) before the disaster to now, do you have less trouble working, more trouble working, or about the same amount?

    Having less trouble working nowHave about the same amount of trouble working nowHave more trouble working now

    Comparing how active you were in things like hobbies, sports, church, or volunteer work before the disaster to now, are you more active, less active, or about the same?

    More active nowAbout the sameLess active now


    The final questions will help us to describe the total group of people who completed the form.


    MaleFemale





    YesNo