adult service evaluation form

Please complete the survey of the services you received from The Cottage. Thank you.

If you have any questions, comments, or concerns, feel free to contact our Crisis Hotline.


This information will only be shared with the organization’s Executive Director for the purpose of improving the services provided for survivors.

Name *
Please include the best number to reach you at.
Directions: Please read the following statements and SELECT the level of agreement or disagreement that best matches your answer. Do not hesitate to add comments, questions, or concerns you have with The Cottage’s services in the space at the end of this section. We appreciate your time and efforts with this evaluation.
Physical and Emotional Needs *
Physical and Emotional Needs
I now have a better understanding of sexual assault and its effects on my life.
I received information about where to place the blame from the assault.
I am now more aware of other sources of help available to me.
The information I received after the medical exam helped me to know what I need to do to take care of my health.
Stability/Resolution: *
I have the support of others to help me cope with the effect of my sexual assault.
Understanding/Participating in the Criminal Justice System *
Understanding/Participating in the Criminal Justice System
I now have a better understanding of how a criminal case is processed from the investigation until the court’s final decision.
I now have a better understanding of my rights as a victim of crime.
Satisfaction *
I was provided with useful referrals to help meet my needs.
I felt like my advocate was there to accompany me to appointments related to my case.
The agency took my culture, religion, and orientation into consideration when providing me services.
Did you know about The Cottage prior to the incident? *
Would you feel confident telling your friends about us if they were in need of our services? *

Thanks for your help!