Please Take A Fews Moments to Complete This Survey!
2007 Relationship Survey


Even though each Citizen Advocacy relationship is unique and independent in it's own right, certain funding sources require documentation of progress made by the CA program. Please answer the following questions as best as you can. With your help we will continue to receive funding from these vital sources.

For further information, call 262-334-3384 or contact Jessica Frederick
Email: jfrederick@cawash.org
Filter Type:
Advocate Name:
Email:


Would you consider your relationship active?
 YES  No


Do you believe that you are free from potential conflicts of interests as an advocate for your partner?
 Yes  No


Spokesperson
 I feel prepared to speak on behalf of my partner  I am willing to speak on behalf of my partner  I have acutally had to act as a spokesperson


Inclusion: I have helped my partner feel like he/she belongs by . . . (check all that pertain)
 Introducing him/her to friends/family  Encouraging him/her to form friendships  Including him/her in community events  Spending quality time with him/her 1-on-1  I feel prepared to respond in this area  I do not feel prepared in this area
Other:


Defense of Rights (check all that pertain)
 I have allowed my partner freedom to make choices  I have defended partner's right of possessions  I have defended partner's right of privacy  I feel prepared to respond in this area  I do not feel prepared in this area
Other:


Protection: Emotional (Check all that pertain)
 Addressed abandonment/loneliness issues  Addressed low self-esteem  I feel prepared to respond in this area  I do not feel prepared to respond in this area
Other:


Protection: Physical (Check all that pertain)
 Talked w/persons in re: medical/physical issues  Aided partner w/diet, exercise &/or hygiene  I feel prepared to respond in this area  I do not feel prepared to respond in this area
Other:


Protection: Sexual (Check all that pertain)
 Talked about concerns w/partner  Followed up concerns w/approp. person  I feel prepared to respond in this area  I do not feel prepared to respond in this area
Other:


Other ways I have been involved in my partner's life that are not mentioned on this survey...


In what ways can the CA staff provide further appropriate assistance for your relationship?
Citizen Advocacy of Washington County | 120 N. Main Street, Suite 350 | West Bend, WI 53095 | P: 262-334-3384 F: 262-334-2075

© Copyright 2008 Citizen Advocacy. All Rights Reserved.