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#act2HELP

Feedback:
Services for Adults

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Feedback - Services for Adults

Ph: 623 1700 - 24/7.

We regularly seek feedback from clients to assist us in providing the best possible service.

Your Name *

First

Last

Your Email *

Phone Number *

On a scale of 1 - 5, with 5 being treated very well, and 1 being not treated well:

Q. 1: How well do you feel that you have been treated at HELP – did you feel welcome, treated with respect, were things explained clearly etc? *

1 2 3 4 5

Comment: *

On a scale of 1 - 5, with 5 being very comfortable, and 1 being not comfortable:

Q. 2: How comfortable did you find the building? (e.g. waiting room, seating, temperature, cleanliness, coffee & tea etc) *

1 2 3 4 5

Comment: *

On a scale of 1 - 5, with 5 being much improved, 3 being no change and 1 being seems worse:

Q. 3: Overall, what change has there been in the problem (s) which led you to seek help? *

1 2 3 4 5

What's improved? *

* Indicates required field

What's not improved? *

On a scale of 1 - 5, with 5 being a lot, and 1 being not at all:

Q.4 To what degree do you think that the assistance you received at HELP contributed to this change? *

1 2 3 4 5

Comment: *

Q. 5: Wast the completion of your counselling / therapy at HELP: *

Agreed together Your decision The counsellor's decision Due to funding ending

If your decision, please comment:

If your decision, please comment: *

On a scale of 1 - 5, with 5 being very helpful, and 1 being unhelpful:

Q.6: If you used the 24 hour telephone support line, how helpful was it? *

1 2 3 4 5

Comment: *

Q.7 : Would you return to HELP if you felt a need for further assistance? *

Yes No I don't know

Why? *

Why not? *

Q. 8: Was there anything about the service that you experienced as being insensitive or inappropriate to you culturally? *

Q. 9: Please describe anything about the service you would have preferred to have been different. *

On a scale of 1 - 5, with 5 being not satisfied, and 1 being very satisfied:

Q. 10: Overall, how satisfied were you with the service you got from HELP? *

1 2 3 4 5

Comment *

Section 2:

Demographic Information
Please tick the box or circle all those categories which apply.

Q. 1: Are you... *

Female Male Other (Please specify)

Specify *

Q. 2: What is your ethnicity? Please tick all those which apply. *

Maori Pakeha Samoan Tongan Cook Islands Niuean Other Pacific European Chinese Other Asian Fijian Indian Other

If you chose 'Other', please describe: *

Q. 3: What Age Group Are You In? *

15-19 20-29 30-39 40-49 50-59 60-69 70+

Q. 4: Did you come to HELP as a:

Survivor of sexual abuse? *

Yes No

Relative of a survivor of sexual abuse *

Yes No

Q. 5: At what age were you sexually abused or assaulted? *

Childhood 0-12 yrs Adolescence 13-16 yrs Young Adulthood 17-24 yrs Adulthood +25 yrs Not sexually assaulted

Q. 5: Approximately how many sessions have you had in the most recent period of counselling at HELP? *

0-5 5-15 16-40 41-80 81+

Thank you for your assistance in giving feedback.

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Telephone

0800 623 1700

Email

info@helpauckland.org.nz

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