Client Screening and Safety Survey
Please complete this survey to help us ensure a safe and positive experience for all clients. Your responses will remain confidential.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your primary reason for seeking our services?
*
How would you rate your current sense of safety in your environment?
*
1
2
3
4
5
Please indicate whether you have experienced any of the following in the past year:
*
Verbal altercations
Physical altercations
Harassment or bullying
None of the above
Other
Please indicate your level of agreement with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel comfortable discussing personal safety concerns.
1
2
3
4
5
I am open to following safety guidelines provided by staff.
6
7
8
9
10
I have previously participated in safety or risk management training.
11
12
13
14
15
Have you ever been involved in a situation where safety was compromised?
*
Yes
No
If yes, please briefly describe the situation and how it was resolved.
Who should we contact in case of emergency? (Name and relationship)
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Survey
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