Domestic Violence Shelter Exit Survey
General Information
Date of Exit
Your Initials
Length of Stay (in days)
Services Used
Counseling
Legal Help
Advocacy
Housing Assistance
Childcare
Other
Experience at the Shelter
Did you feel safe during your stay?
Yes
No
Were your needs met during your stay?
All
Most
Some
None
Recommendations
What could we do to improve our services?
Any additional feedback or suggestions?
Aftercare Information
Would you like information about aftercare services?
Yes
No
Preferred Contact Method
Phone
Email
Other
Contact Details