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1-866-4 EXHALE
Monday – Friday:
5 p.m. – 10 p.m. Pacific
Saturday – Sunday:
12 p.m. – 10 p.m. Pacific

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Caller Feedback Form

If you have called the Exhale talkline, we would appreciate your honest feedback about the service you received. You may fill out as much or as little of this form as you want. The more information we have about our callers and how you feel about the service you received, the more equipped we are to improve the quality of services we offer. We appreciate your time and attention. All information is completely confidential and used for the internal purposes of Exhale.

 

Your Name:
Counselor Name:
Date of call:
Time of call:

 

What city and state did you call from?

enter city

 

Please pick what describes you best
Woman who had an abortion/s
Intimate Partner
Friend
Family Member   *
Other   *

* please explain:

 

What Type of Abortion/s occurred?
Surgical/D&C/MVA
Medical/RU486
Don't Know
Other

 

When did you have your Abortion/s?

 

What is your gender?
Male
Female
Transgender

 

How old are you?

What is your Race/Ethnicity?

What is your primary language?

What is your religious or spiritual practice (if any)?

 

How did you Learn About Exhale?
Abortion Provider
Community Organization
Faith Organization/Leader
Media
Internet
Friend/Significant Other
Other   *

* enter name:

 

Please describe your experience of the call:
Why did you call? Did you get what you needed? What did the counselor do well? What would you have liked to have gotten that you didn’t get?

 

Please rate your overall experience calling the Exhale talkline:
Super helpful
I’m glad I called
It didn’t really help me

 

 

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Llame a Exhale para platicar libremente sobre su experiencia con aborto. Se puede solicitar consejeras bilingues. Siempre hay consejería disponible en español los miercoles, 5 p.m. – 10 p.m.

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