Feedback Form

Thank you for taking the time to share your feedback with us. We always welcome feedback and would love to hear yours. We collect your feedback to help improve our service and follow up on any issues that you raise.

The form below will take around 5 mins to complete. Please be assured your information will be kept confidential and will in no way affect the support you receive from our service or from ACC.

Choose the type of service that you received from Specialist Rehab Services:

Social Rehabilitation( IRA, Equipment, SNA, Single Discipline assessment)
Training for Independence Programme
I don’t know

How happy are you with our service?

Have your experiences with Specialist Rehab Services been positive? If so please let us know what you liked about our service. If not please let us know so that we can do better.

Overall how would you rate your satisfaction with Specialist Rehab Services?
1= Very Dissatisfied, 10 = Very Satisfied

Please enter anything else you would like us to know.

Gender

Male
Male

Which age group are you in?

0-19
20-65
65+

Which main ethnic group do you associate yourself with?

Maori
European
Pacific Island
Asian
African
Other - please specify below

If other:

You may wish to share the following details:

Date
Client name
Therapist name
Day time phone

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
Was the assessor timely (i.e. arrived on time)
Did you understand the assessment process when it was explained to you?
Did you feel comfortable talking to the assessor?
While you were receiving the above service from SRS did you feel you were fully informed of what was happening?
Do you feel the assessor had a good understanding of your needs?
Was the assessor respectful in your home?
Do you think the assessor/therapist was culturally respectful?
Did the assessor talk to you about the consent form and did you understand this?