Name

Best way to reach you? Best way to reach you?E-mailTelephone

Is this a secure e-mail? Is this a secure e-mail?YesNo

E-mail

Telephone number

Can we leave a voicemail or text? Can we leave a voicemail or text? Yes No

Which service(s) did you use? Which service(s) did you use? Shelter Counselling (domestic violence) Counselling (sexual assault) Counselling (other) Transitional support and housing assistance Traite des personnes Human trafficking Child witness Workshops Awareness presentation

Where do you live? Where do you live?TimminsIroquois FallsCochraneKapuskasingHearstOther

Other location :

Were the services offered to you virtually or in person? Were the services offered to you virtually or in person? Virtual In person

Did the service you received help you reach your goals? Did the service you received help you reach your goals? Not at all Acceptable Yes Very much

Comments :

Is there anything we can do to improve your experience when accessing our services?

Were you able to reach a worker easily? Were you able to reach a worker easily? Not at all Acceptable Yes Very easily

During intake, were the following clearly explained to you : During intake, were the following clearly explained to you :

The agency's services The agency's services Yes No

The confidentiality agreement The confidentiality agreement Yes No

The role of the worker The role of the worker Oui Non

The safety plan The safety plan Yes No

Other comments :