Feedback Survey

What service did you receive support from?*

e.g. Mental Health Alcohol & Drug Counselling, Well Child /Tamariki Ora, Kaupapa Community Nursing Service, Asthma & Respiratory Nurse Educator Service, Bay Facilitation Service, Nutrition & Physical Activity, Kaupapa Antenatal & Parenting, Kaumatua Programme, Community Action Youth & Drugs

Client ID*

Section 1

How did you find out about our service?*

Word of Mouth
Agency
Friend
Staff

What is your ethnic group?*

Maori
European
Pacific

What Iwi are you affiliated to?*

What is your gender?*

Male
Female

Which age group are you in?*

6-15 years
16-25 years
26-64 years
65+ years

Section 2

How long did you wait to get a response from when you first contacted our service? Please rate your satisfaction*

Very Dissatisfied
Dissatisfied
Satisfied
Very Satisfied

Any comments about response time

Overall, how satisfied were you with the care you/your whanau member received?*

Very Dissatisfied
Dissatisfied
Satisfied
Very Satisfied

Any comments about your care

Would you recommend this service to your family/whanau and friends?*

Very Dissatisfied
Dissatisfied
Satisfied
Very Satisfied

Any comments about recommending our services

What cultural input e.g. karakia, whakapapa, empathy, kaumatua support, did you have into your care and how did it help?

What changes or improvements would you like to see within the service? If any:

About the Kaimahi

How satisfied were you with staff helpfulness in providing assistance?*

Very Dissatisfied
Dissatisfied
Satisfied
Very Satisfied

Any comments about staff helpfulness

Consent

Would you like a phone call or email to discuss your care more thoroughly?*

This information will remain strictly confidential

Yes
No

Kōrero Mai

Have your say

How was our service?

Please assist us to provide better services by completing this Survey. Your comments are completely anonymous and will be used for ongoing improvements.

Section 1

Section 2

About the Kaimahi

Consent