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* 1. Person providing feedback:

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* 2. Name (optional):

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* 3. When thinking about your first experience of contacting and meeting Kern staff, please consider the extent to which you agree or disagree with the following statements: 

  Strongly disagree  Disagree  Neither agree nor disagree  Agree  Strongly agree 
My experience was positive
The staff were knowledgeable and helpful 
I felt confident that the services received would meet my expectations 
I felt heard and understood 
All my/my family member’s questions were answered 

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* 4. When thinking about your current Kern service, please consider the extent to which you agree or disagree with the following statements: 

  Strongly disagree  Disagree  Neither agree nor disagree  Agree  Strongly agree 
My Key Worker is knowledgeable and helpful 
My therapy team is knowledgeable and helpful 
I feel confident in my therapy team’s ability to help reach my goals and achieve positive outcomes 
I have choices about how and when therapy is delivered 
My/ my family member’s privacy and confidentiality is always respected 
Kern staff have provided me with relevant documentation to support me during my NDIS plan review process 

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* 5. I have received a copy of Kern’s Easy Read Feedback and Complaints Brochure: 

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* 6. I have received a copy of Kern’s Easy Read Guide to the Service Agreement 

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* 7. When thinking about your Kern service experience overall, please consider the extent to which you agree or disagree with the following statements: 

  Strongly disagree  Disagree  Neither agree nor disagree  Agree  Strongly agree 
I feel comfortable providing feedback about Kern or making a complaint 
I know how to provide feedback about Kern or make a complaint 
Overall, I am happy with the service Kern provides 
The service I have received from Kern so far has met my expectations 
I would recommend Kern therapy supports to others 

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* 8. If you disagreed or strongly disagreed with any of the above questions, what suggestions do you have for Kern to improve the quality of service delivery or our policies and procedures?

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* 9. Is there anything that Kern does particularly well that we should keep doing?

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* 10. If you self manage your funding, or have a Plan Manager, do you have any feedback on Kern’s system of invoicing? (Leave blank if not applicable)

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* 11. Are there any other therapy related services and supports you would like Kern to offer? 

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* 12. Are there any policies and/or procedures you would like a copy of, or would like to provide feedback on? 

Thank you for taking the time to complete this form.
Your honest feedback is highly valued and will enable us to continually improve Kern Allied Health services.

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