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Client Services Survey

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How old are you?

Under 18

18-25

26-30

31-35

36-40

41-50

Over 50

Are you currently employed?

Yes

What is your current schooling level?

Do you currently live in Dublin?

What is the name of the area that you are from?

How would you define your current relationship status?

Single

Dating

Married

Separated

Divorced

Widowed

In the past, which clinics have you attended?
(Please tick all that apply.)

This is my first visit to an IFPA clinic.

Cathal Brugha Street (Before 2002)

Cathal Brugha Street EveryWoman Centre (After 2002)

Tallaght Clinic

Synge Street Clinic

How did you hear about the IFPA?

Website

Word-of-Mouth

Referral from GP

Independent Directory

Phone Book

Golden Pages

Positive Options

Crisis Pregnancy Agency

Leaflet

Other

Do you have any other comments about the IFPA's advertising?

	I know the IFPA offers this service.	I have used this service before.	I will use this service today.
Consultation for Contraception	I know the IFPA offers this service.	I have used this service before.	I will use this service today.

The Pill	I know the IFPA offers this service.	I have used this service before.	I will use this service today.

NuvaRing	I know the IFPA offers this service.	I have used this service before.	I will use this service today.

The Coil-IUCD	I know the IFPA offers this service.	I have used this service before.	I will use this service today.

Hormonal Coil-Mirena	I know the IFPA offers this service.	I have used this service before.	I will use this service today.

Depo-Provera	I know the IFPA offers this service.	I have used this service before.	I will use this service today.

The Cap-Diaphragm	I know the IFPA offers this service.	I have used this service before.	I will use this service today.

Vasectomy	I know the IFPA offers this service.	I have used this service before.	I will use this service today.

Emergency Contraception	I know the IFPA offers this service.	I have used this service before.	I will use this service today.

Pregnancy Testing	I know the IFPA offers this service.	I have used this service before.	I will use this service today.

	I know the IFPA offers this service.	I have used this service before.	I will use this service today.
Pregnancy Counselling	I know the IFPA offers this service.	I have used this service before.	I will use this service today.

Psychosexual counselling	I know the IFPA offers this service.	I have used this service before.	I will use this service today.

Chlamydia Testing	I know the IFPA offers this service.	I have used this service before.	I will use this service today.

Post-Abortion Counselling	I know the IFPA offers this service.	I have used this service before.	I will use this service today.

Cervical Screening (Smear)	I know the IFPA offers this service.	I have used this service before.	I will use this service today.

Information Services	I know the IFPA offers this service.	I have used this service before.	I will use this service today.

Post-Abortion Support Group	I know the IFPA offers this service.	I have used this service before.	I will use this service today.

Breast Cancer Awareness	I know the IFPA offers this service.	I have used this service before.	I will use this service today.

Are there any other services that you wuld like us to offer?

Are you interested in being tested for any Sexually Transmitted Infections?

Yes

At your appointment, do you ususally come with a partner or friend?

Yes

Are you attending the clinic with a friend, relative, or partner today?

Yes

Do you have any children?

Yes

Do you feel our facilities meet the needs of those accompanying you?

Yes

Don't know

If the IFPA does not meet the needs of those accompanying you, can you suggest how we can improve our facility for you?

Would you be interested in having access to information on any of the following topics? (Please tick all the apply)

Emergency Contraception

Methods of Contraception

Prenatal Care/Health

Talking to your partner about Contraception

How to do a Breast Self-Exam

Where to go for information about abortion

For ParentsL How to talk to kids about Sex and Relationships

Menopause

General Health

Medical Cards

How to Campaign for Family Planning Services and Sexual Health Issues

Other

If you were to receive information for any of the topics above, what format would you like to receive it in?

Leaflets available in the waiting room

Leaflets available in the nurses' room

Leaflets available in the doctors' room

Phone Help-Line

From a person you could ask

Through workshops

Information on the IFPA Website

Posters throughout the Clinics

Other

Will you return to this clinic or another IFPA clinic?

Yes

Will you refer any friends or relatives to an IFPA clinic?

Yes

Do you have any additional comments about your visit today?

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Client Services Survey

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