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Can you help us fly? Your story and experience at the Dove Service are important to us, not just to understand how we have supported you (and ways we could improve on that support) but for us to share with others who may be considering using our services, our funders, and for the public to understand what we do so that they can support our fundraising efforts.

Please select the most appropriate answer for the questions, please click n/a (not applicable) if the question does not apply to you:

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Name of Counsellor *

Date of Last Appointment

Time of Last Appointment *

My counsellor was supportive in addressing any issues with me?Definitely TrueTrueNeutral/Not SureFalseDefinitely False

I was treated with dignity and respectDefinitely TrueTrueNeutral/Not SureFalseDefinitely False

How likely is it that you would recommend this service to someone with a similar need?Extremely LikelyLikelyUnlikelyExtremely Unlikely

How satisfied were you with your counsellor overall?Very SatisfiedSatisfiedNeutral/Not SureDissatisfiedVery Dissatisfied

Has the counselling had positive impact on your life?DefinitelyIn Some WaysNeutral/Not SureNot at allNegative impact

Has the counselling helped improve your health?DefinitelyIn Some WaysNeutral/Not SureNot at allNegative impactn/a

Has the counselling helped improve your relationships with friends/family/partners?DefinitelyIn Some WaysNeutral/Not SureNot at allNegative impactn/a

Has the counselling helped reduce the number of visits to your GP?DefinitelyIn Some WaysNeutral/Not SureNot at allNegative impactn/a

Has the counselling helped reduce harmful behaviours (e.g drug/alcohol use)?DefinitelyIn Some WaysNeutral/Not SureNot at allNegative impactn/a

Has the counselling helped you feel more relaxed and/or improve your sleep pattern?DefinitelyIn Some WaysNeutral/Not SureNot at allNegative impactn/a

Has the counselling helped you make any changes you wanted to make?DefinitelyIn Some WaysNeutral/Not SureNot at allNegative impactn/a

How satisfied were you with your overall experience?Very SatisfiedSatisfiedNeutral/Not SureDissatisfiedVery Dissatisfied

We would be very grateful if you could tell us below what you have gained from our services and how we have helped you. What brought you to us? What difference(s) have we supported you to make? What would you tell others who may need our support?

I give the Dove Service permission to use my story (anonymously) in their marketing/PR

• Yes
• No

Can we contact you again? Sometimes we need to ask our clients for support in the future. Please click the boxes below if you would be happy for us to contact you for support with:

• Fundraising
• Stories for the press
• Volunteering

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If you are experiencing any issues in submitting this form, please contact @Enquiries.