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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:

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

1: 2: 3: 4: 5: 6: 7: 8: 9: 10:

Please enter anything else you would like us to know.

Gender

Which age group are you in?

Which main ethnic group do you associate yourself with?

If other:

You may wish to share the following details:

Date
Client name
Therapist name
Day time phone

©2014 Specialist Rehab Services Ltd • PO Box 537 • Silverdale • Auckland 0944 • Feedback Form Admin • Staff Forum