Empowerment and Satisfaction-Questionnaire- Long Form (ESQ-LF)
As a client of our agency, you received services in response to a traumatic event(s). In order to provide the best possible services, we would like to know how much our agency helped you to deal with that particular trauma. Please read the following statements about the services and other aspects of the agency and mark if you strongly agree, somewhat agree, are neutral (don't feel strongly one way or the other), somewhat disagree, or strongly disagree with the statements.
The service I received was a result of
Clear selection
What did you receive?
Clear selection
Staff respected my background
(e.g. gender, race, culture, ethnicity, sexual orientation, disability, lifestyle, etc.)
Strongly disagree
Strongly agree
Clear selection
Services were available at times that were good for me
Strongly disagree
Strongly agree
Clear selection
I was asked to participate in deciding what services I would receive
Strongly disagree
Strongly agree
Clear selection
I feel the staff heard me
Strongly disagree
Strongly agree
Clear selection
I received the kind of services I wanted
Strongly disagree
Strongly agree
Clear selection
Staff helped me believe that my life could change for the better
Strongly disagree
Strongly agree
Clear selection
The services I received helped me deal more effectively with problems
Strongly disagree
Strongly agree
Clear selection
Because of the services I received, I learned coping skills to help me deal with trauma
Strongly disagree
Strongly agree
Clear selection
The services I received helped me identify a support system
Strongly disagree
Strongly agree
Clear selection
The services I received helped me become aware of how crisis and trauma affect my life
Strongly disagree
Strongly agree
Clear selection
The services I received helped me plan for my safety
Strongly disagree
Strongly agree
Clear selection
The staff informed me about my victims rights
Strongly disagree
Strongly agree
Clear selection
The services I received helped me cope with my fear for my safety
Strongly disagree
Strongly agree
Clear selection
Because of the services I received, I know more about the options and choices available to me overall
Strongly disagree
Strongly agree
Clear selection
I would return to this agency if I needed victim services in the future
Strongly disagree
Strongly agree
Clear selection
I would recommend this agency to a friend in need of victim services
Strongly disagree
Strongly agree
Clear selection
In an overall, general sense, I am satisfied with the services I received
Strongly disagree
Strongly agree
Clear selection
Because of services I received, I know about community resources that are available to me
Strongly disagree
Strongly agree
Clear selection
Is there anything else you would like to say?
Section B:
If you visited our facility, please answer the following questions. If you never visited our facility, skip to Section C
I was able to get around the building easily
Strongly disagree
Strongly agree
Clear selection
The facilities were comfortable for me
Strongly disagree
Strongly agree
Clear selection
Is there anything else you would like to say?
Section C:
If someone from our agency met you at an emergency medical facility, please answer the following questions about the services we provided. If not, please skip to Section D
I felt supported through the medical system by staff from the agency
Strongly disagree
Strongly agree
Clear selection
Because of the services I received, I now know more about the medical system
Strongly disagree
Strongly agree
Clear selection
Is there anything else you would like to say?
Section D:
If someone from our agency accompanied you through the legal process, please answer the following questions about the services we provided. If not, please skip to Section E
I felt supported through the legal system by staff from this agency
Strongly disagree
Strongly agree
Clear selection
Because of the services I received, I now know more about the legal system
Strongly disagree
Strongly agree
Clear selection
Is there anything else you would like to say?
Section E:
If you had any of the following out-of-pocket (not covered by any type of insurance) financial losses as a direct result of the victimization, please answer the following questions. If you did not have any of these out-of-pocket losses, please skip to Section F
The agency made me aware of the Pennsylvania Victim Compensation Program
Strongly disagree
Strongly agree
Clear selection
The information provided by the agency helped me understand the victim compensation process
Strongly disagree
Strongly agree
Clear selection
Is there anything else you would like to say?
Section F:
Please consider the following reactions which sometimes occur after a traumatic event. This section is concerned with your personal reactions to the traumatic event which happened to you. Please answer the following questions
How much have you been bothered by unwanted memories, nightmares, or reminders of the event?
Not at all
Very much
Clear selection
How much effort have you made to avoid thinking or talking about the event, or doing things which remind you of what happened?
Not at all
Very much
Clear selection
To what extent have you lost enjoyment for things, felt sad or depressed, kept your distance from people, or found it difficult to experience feelings?
Not at all
Very much
Clear selection
How much have you been bothered by poor sleep, poor concentration, jumpiness, irritability or feeling watchful around you?
Not at all
Very much
Clear selection
How much have you been bothered by pain, aches, or tiredness?
Not at all
Very much
Clear selection
How much would you get angry or upset when stressful events or setbacks happened to you?
Not at all
Very much
Clear selection
How much have you been blaming yourself or feeling guilty for what happened to you?
Not at all
Very much
Clear selection
How much have the above symptoms interfered with your ability to work or carry out daily activities?
Not at all
Very much
Clear selection
How much have the above symptoms interfered with your relationships with family or friends?
Not at all
Very much
Clear selection
How much better do you feel since beginning services? (as a percentage)
0% No change
100% as well as I could be
Clear selection
Overall, how much have the above symptoms improved since starting services?
Clear selection
What did you find helpful about our services?
What did you find not helpful about our services? Please include any suggestions you have for improvement.
Type of victimization
(check all that apply to your current situation)
Primary income source
How long did you receive services from our agency?
Clear selection
Ethnic Origin
Clear selection
Marital/Relation (if adult)
Clear selection
Type of services received
(check all that apply)
Have you had prior victimizations?
If yes, what type of prior victimizations have you encountered?
Education
Clear selection
Date of birth
MM
/
DD
/
YYYY
Household income
Clear selection
Gender
Clear selection
Disability
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