RACF Client Session Feedback Form Survey

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* 1. Please indicate who referred you to this service:

Psychiatrist

Aged Care Nurse

Self Referral

Other (please specify)

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* 2. Did Someone help you complete this survey?

Yes - Someone from the program

Yes - Aged Care Facility Staff Member

Yes - Someone Else

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* 3. Where did you receive this service?

Aged Care Facility Name:

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* 4. What is your age range?

Under 65

66-70

71-75

76-80

81-85

86-90

91-95

96-100

Over 100

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* 5. Gender:

Male

Female

I prefer not to say

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* 6. Feedback about the referral into the program:

	Yes	No	Unsure
I was satisfied that my confidentiality and privacy was ensured at all times.	I was satisfied that my confidentiality and privacy was ensured at all times. Yes	I was satisfied that my confidentiality and privacy was ensured at all times. No	I was satisfied that my confidentiality and privacy was ensured at all times. Unsure
The referral process was clear and easy.	The referral process was clear and easy. Yes	The referral process was clear and easy. No	The referral process was clear and easy. Unsure
My referrer discussed the referral process with me, including consent issues.	My referrer discussed the referral process with me, including consent issues. Yes	My referrer discussed the referral process with me, including consent issues. No	My referrer discussed the referral process with me, including consent issues. Unsure
I was satisfied with how the referral occurred.	I was satisfied with how the referral occurred. Yes	I was satisfied with how the referral occurred. No	I was satisfied with how the referral occurred. Unsure

Do you have any feedback about the referral?

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* 7. Feedback about my time with the mental health provider

	Yes	No	Unsure
I was satisfied that my confidentiality and privacy was ensured at all times.	I was satisfied that my confidentiality and privacy was ensured at all times. Yes	I was satisfied that my confidentiality and privacy was ensured at all times. No	I was satisfied that my confidentiality and privacy was ensured at all times. Unsure
I found it easy to make an appointment with my mental health provider.	I found it easy to make an appointment with my mental health provider. Yes	I found it easy to make an appointment with my mental health provider. No	I found it easy to make an appointment with my mental health provider. Unsure
I have a better understanding of my mental health as a result of this service.	I have a better understanding of my mental health as a result of this service. Yes	I have a better understanding of my mental health as a result of this service. No	I have a better understanding of my mental health as a result of this service. Unsure
I feel more able to manage my mental health since I have received the service(s).	I feel more able to manage my mental health since I have received the service(s). Yes	I feel more able to manage my mental health since I have received the service(s). No	I feel more able to manage my mental health since I have received the service(s). Unsure
The information I received from the counsellor was useful in helping me with my issues.	The information I received from the counsellor was useful in helping me with my issues. Yes	The information I received from the counsellor was useful in helping me with my issues. No	The information I received from the counsellor was useful in helping me with my issues. Unsure

Do you have any further comments about the mental health provider and the treatment you have received:

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* 8. Overall, how would you rate the service you received from the mental health provider?

Very Poor

Poor

Good

Very Good

Excellent

Very Poor

Poor

Good

Very Good

Excellent

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* 9. I have had counselling in the past?

Yes

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* 10. If you had not been referred to this program, would you have sought treatment from elsewhere?

Yes

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* 11. If no, which of the following best applies about why you would not have sought treatment from elsewhere?

Concerns about cost

Worried about what other people would think

Unsure about other services available to me

I don’t think my condition is bad enough

I had difficulties accessing the location of the service

I was not able to access transport

Other (please specify)

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* 12. I would recommend this service to my friends or family if they needed it.

Yes

Unsure

RACF Client Session Feedback Form

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* 1. Please indicate who referred you to this service:

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* 2. Did Someone help you complete this survey?

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* 3. Where did you receive this service?

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* 4. What is your age range?

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* 5. Gender:

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* 6. Feedback about the referral into the program:

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* 7. Feedback about my time with the mental health provider

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* 8. Overall, how would you rate the service you received from the mental health provider?

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* 9. I have had counselling in the past?

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* 10. If you had not been referred to this program, would you have sought treatment from elsewhere?

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* 11. If no, which of the following best applies about why you would not have sought treatment from elsewhere?

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* 12. I would recommend this service to my friends or family if they needed it.

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* 13. In your opinion what are the best things about this service?

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* 14. If you could change one thing about the service what would it be?