Hidden field for surname*

Date Completed.*

Who referred you to Survive?

If Other, please state

After accessing Survive’s services I feel better able to cope with aspects of everyday life

I can cope better with my feelings and emotions

I am able to use strategies to self-soothe and ground myself when faced with triggers, flashbacks etc 

I better understand my thoughts and behaviours

I feel less shame, self-blame and guilt

I am better able to care for myself

I have been able to reconnect with my life

I have been able to reconnect with others (friends, family, relationships etc) 

I am more positive and optimistic for the future

I feel safer

I was able to build a trusting, working relationship with my support worker / counsellor / therapist

My support worker / counsellor / therapist had the correct skills to work with my needs

I felt supported, listened to and understood

I felt empowered, in control and able to make my own, informed decisions

I have met the objectives/goals first identified in my initial session

The number of sessions available were sufficient for my needs

I was satisfied with my overall experience of accessing Survive’s services

Did you receive all the support that you required at Survive?

Did the support you received help with your engagement with the Criminal Justice System?

Did you report the crime to the police during/after your engagement with Survive?

Counselling (10 weeks)

Counselling/trauma therapy (20 weeks)

Support Work

Group Work

Please use this space for any additional comments about accessing support online or via the telephone

Please use this space for any positive comments about your experience of Survive services for use in advertising, applications for funding and performance reports.

Are there any other comments or suggestions for improvements that you would like to make regarding your experience of Survive