About this survey

Healthwatch Hounslow gives local people the chance to say what they think about how local health and social care services are run. Your experiences are important to us and help us to let local decision makers and service providers know what's working and what isn't. Please take a few minutes to share your experiences with us.

To understand how your information will be used please read the 'How we use this information' section at the end of the survey.

Community and Other Services Feedback

If you've used any community or other services, such as pharmacies, mental health services, social care, voluntary organisations or community centres, in the last 12 months, please complete this part of the survey. If not, please scroll to the next section.

*Name of Community or 'Other' service(Required.)

*What works well at this service ?(Required.)

*What is not working well, and what could be improved?(Required.)

*Any other comments?(Required.)

Tell us a bit about you

It would really help to know a little more about you to help us improve equality, diversity and inclusion.

*What gender do you identify yourself as?(Required.)

Male

Female

Trans

Non-binary

Other

Prefer not to say

*Your age(Required.)

18 to 24 years

25 to 34 years

35 to 44 years

45 to 54 years

55 to 64 years

65 to 74 years

75 to 84 years

85 years and over

Prefer not to say

*Tell us about your ethnicty(Required.)

White - English / Welsh / Scottish / Northern Irish / British

White - Irish

White - European

White - Other (please see below)

European

Arab

Asian / Asian British – Indian

Asian / Asian British – Pakistani

Asian / Asian British – Bangladeshi

Chinese

Any other Asian background (please see below)

Black / Black British – African

Black / Black British – Caribbean

Any other Black background (please see below)

Gypsy, Roma or Traveller

Latin American

Mixed - Asian and White

Mixed - Black African and White

Mixed - Black Caribbean and White

Any other Mixed / Multiple ethnic background (please see below)

Prefer not to say

Other - Not listed (please see below)

Other: If you answered 'Other' to any of the above, please write your answer here:

*Do you have a disability?(Required.)

Yes

No

Prefer not to say

*Do you have a long-term health condition?(Required.)

Yes

No

Prefer not to say

Consent

Please provide your consent so that we can use and store the information you have provided.

*Confirmation of consent(Required.)

I consent to sharing the information provided with Healthwatch Hounslow and Public Voice, and undertand that it will be stored securely.

How we use your information

Any information used will be anonymised, and your name will not be used. The information you share with us may be accessed by Healthwatch England and Public Voice, and shared with local health and care service commissioners and providers. Your answers will help us to identify areas for improvement in local health and care and report on them.

Our full privacy statement can be found at:
https://www.healthwatchhounslow.co.uk/privacy-policy/