| Thinking about your recent visit... |
| 1 | Thinking about the service we provide, overall, how was your experience of our service?
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| 2 | Please tell us anything that was particularly good
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| 3 | Please tell us about anything that we could have done better
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| 4 | I am treated with respect and dignity.
Being treated with respect and dignity means you are listened to, your feelings are considered, and people are kind, fair and polite.
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| 5 | How was your appointment held with the service?
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| 6 | Were you offered a digital (online video) appointment with the service at the time of booking?
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| 7 | If you chose to have a face-to-face appointment and not to have an online video appointment, can you tell us your reasons for this?
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| Physical barrier (e.g. hard of hearing, eyesight barrier, etc) |
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Language barrier |
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| Lack of access to technology or confidence with technology |
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Felt face-to-face would be better to diagnose or help |
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| Other |
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| N/A |
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| 8 | If you contacted our service by phone how would you rate your call experience with the agent?
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| 9 | If you had any interaction with our reception staff on the day of your appointment, how would you rate your interaction?
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| 10 | Do you have any feedback that you would like to share regarding your interaction with the reception staff/call handler?
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| About you |
| 11 | Age..
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| 12 | Do you or the person you are providing feedback for identify themselves as having special educational needs and/or disabilities?
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| 13 | We run regular service user engagement events and focus groups and use patient stories to help improve our services. You would not need to leave home; you can connect using your mobile phone, computer or laptop. Would you like to be contacted about these opportunities? If you would like to be contacted please leave your contact details below.
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| 14 | The service may wish to contact you for some more information about your experience with the service. If you are happy to be contacted please choose Yes. If you do not consent to being contacted please choose option No.
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| 15 | Please include your contact details:
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| 16 | The following information is voluntary and you are welcome to remain anonymous.
Name:
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| 17 | Address:
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| 18 | Contact Number:
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| 19 | Email Address:
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| We would be very grateful if you could answer some questions about you. You may wonder why we ask personal questions, or fear that your answers could affect your care in a negative way; in fact, the more you tell us about you, the better we can understand your needs. We can then give you care and treatment in the best way for you as an individual. Responding to these questions is entirely voluntary and any information provided will remain anonymous and treated in the strictest confidence. |
| 20 | Are you happy to answer some additional questions?
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| 21 | What is your postcode:
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| 22 | Please tell us your age.
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| 23 | What is your relationship status?
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| 24 | Are you currently pregnant?
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| 25 | Have you given birth within the last 12 months?
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| 26 | Do you consider yourself to have a disability or long term condition? This includes any health condition or disability that impacts on your daily life which you have had for 12 months or more. You may have learnt to manage your disability/long-term condition, but it still counts.
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| 27 | How would you describe your disability or long term condition?
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| Physical Condition / disability |
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Mental health condition |
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| Long term health condition |
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Neurodiversity |
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| Learning difficulty |
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Other long term health condition (please specify below) |
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| Other impairment (please specify below) |
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I do not wish to disclose whether or not I have a disability or long term condition |
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| N/A |
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| 28 | Ethnicity
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| 29 | Asian or Asian British
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| 30 | Black or Black British
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| 31 | White
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| 32 | Mixed
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| 33 | Other Ethnic Group
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| 34 | Are you:
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| 35 | Is your gender identity the same as the gender you were given at birth?
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| 36 | Sexual Orientation
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| 37 | Religion or Belief
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