EXIT SURVEY (ANONYMOUS)
To be given to every client on her first visit, along with a self-addressed stamped envelope.
Please take a few minutes to answer these questions. Circle the answer that best describes
your opinion, or fill in the blank. We need you to be honest in your answers because your
suggestions will help us improve services. This is anonymous, so we will never know who
this survey came from. THANK YOU FOR YOUR TIME AND HELP!
1.
I was treated with respect and professionalism the first time I called on the phone.
Strongly disagree
2.
Undecided
Agree
Strongly agree
Agree
Strongly agree
I felt welcomed when I walked into the office.
Strongly disagree
3.
Disagree
Disagree
Undecided
All of my questions were answered completely and honestly by Crossroads staff.
Strongly disagree
Disagree
Undecided
Agree
Strongly agree
4.
If not, please explain: _________________________________________________
___________________________________________________________________
___________________________________________________________________
5.
Did you have any problems during your visit?
_____Yes
_____No
If Yes, Please describe: ________________________________________________
___________________________________________________________________
6.
The room I sat in while talking with my Client Advocate was comfortable
Strongly disagree
Disagree
Undecided
Agree
Strongly agree
7.
How would you improve that room?_______________________________________
8.
What is your Client Advocate’s name? _____________________________________
9.
I felt comfortable talking about my concerns with my Client Advocate.
Strongly disagree
10.
Undecided
Agree
Strongly agree
I trust my Client Advocate.
Strongly disagree
11.
Disagree
Disagree
Undecided
Agree
Strongly agree
Please include any additional comments regarding the Client Advocate who helped
you: _______________________________________________________________
___________________________________________________________________
___________________________________________________________________
12.
All Crossroads staff has been honest with me about the services they provide.
Strongly disagree
13.
Disagree
Undecided
Agree
Strongly agree
I received all of the information I needed to make an informed decision.
Strongly disagree
Disagree
Undecided
Agree
Strongly agree
14.
If you received abortion alternatives counseling, what was the MOST helpful to you
in making your decision? _______________________________________________
___________________________________________________________________
___________________________________________________________________
15.
What was the LEAST helpful? ___________________________________________
___________________________________________________________________
___________________________________________________________________
16.
Did you watch any video? If so, what was it about and how did it affect you?
___________________________________________________________________
___________________________________________________________________
17.
If a friend of mine was in my situation, I would recommend she come here for help.
Strongly disagree
Disagree
Undecided
Agree
Strongly agree
18.
How do you feel about Crossroads’ staff and services overall? _________________
___________________________________________________________________
___________________________________________________________________
19.
How can we improve the Center or our services? ____________________________
___________________________________________________________________
___________________________________________________________________
20.
If Crossroads’ services or staff has made a difference in your well-being or your
decision regarding pregnancy or sexual integrity, please describe below in detail:
______________________________________________________________
______________________________________________________________
______________________________________________________________
ALL DONE! DROP THE SELF-ADDRESSED STAMPED ENVELOPE WITH THIS SURVEY
IN ANY MAIL RECEPTACLE! EASY AS THAT!
THANKS! YOUR OPINION WILL HELP US TO BETTER SERVE YOU & OTHERS!