Exit / Feedback Survey

Service Name

Service stream

Age

0-20

20-30

30-40

40-50

Over 50

Who are you filling out the survey for?

Yourself

Your Child

Other ....................................................................................

Which best describes your ethnicity?

Please complete ................................................................................................................

Please identify your gender

............................................................................................................................................................

Did the quality of support provided to you (or your child) meet with your expectations?

Strongly agree

Agree

Disagree

Strongly disagree

Did the staff provide you with all the relevant information regarding the service?

Strongly agree

Agree

Disagree

Strongly disagree

Do you feel your (Childs) rights have been upheld by the staff?

Strongly agree

Agree

Disagree

Strongly disagree

Do you feel your cultural and spiritual needs have been met by the staff?

Strongly agree

Agree

Disagree

Strongly disagree

Do you feel the staff have supported you (your child) adequately to achieve your (their) goals?

Strongly agree

Agree

Disagree

Strongly disagree

Did you find the staff in general approachable?

Very approachable

Approachable

Not very approachable