CLIENT FEEDBACK FORM Please help us improve our service by completing a short survey on the service you received Question Title * 1. How would you rate the intake process? poor ok neutral good very good N/A poor ok neutral good very good N/A Other (please list) Question Title * 2. The wait time for service was reasonable poor ok neutral good very good poor ok neutral good very good Additional Information Question Title * 3. How did you hear about the RIAC? Family member Friend Service provider Government Department Social Media Community Organisation Previous client or carer Other (please list) Question Title * 4. Which RIAC Program did you access Advocacy Access and Support NDIS Appeals Aboriginal and Torres Strait Islander Advocacy Strengthening Parents Support Program RIAC Forms Clinic Other (please specify) Question Title * 5. Are you happy with the support or advice that you received? Yes No Other (please specify) Question Title * 6. How likely would you be to recommend RIAC to someone else? not at all unlikely neutral likely very likely not at all unlikely neutral likely very likely Other (please specify) Question Title * 7. At which site did you access support? Shepparton Bendigo Geelong Horsham Mildura Swan Hill Online/by phone only Question Title * 8. Which staff member assisted you? Fiona Rhiannon Jackie Nikola Florence (Flow) Joseph Amanda Anna Ellen Mark Nicole Clare Karryn Rachael Roz Tanya Terri-ann Annie Rusi Felicity Other (please specify) Question Title * 9. Did the staff member provide you with tools to build on your own self advocacy skills (if applicable)? Yes No Please explain Question Title * 10. Is there more information you would like to receive so that you can continue to build on your advocacy skills? Yes No Please explain Question Title * 11. Do have any suggestions to improve our service? Yes No Please explain Question Title * 12. Did RIAC provide you with information in a form you could understand? Yes No If No please explain Question Title * 13. Did staff work with you in a respectful and supportive way? Yes No If no please explain Question Title * 14. Did the service provide a private space for confidential discussions? Yes No If no please explain Question Title * 15. How would you rate the staff member's skill and knowledge? poor ok neutral good very good poor ok neutral good very good Additional Information Question Title * 16. My independent needs were supported including consideration of any language, cultural or diversity needs. poor ok neutral good very good poor ok neutral good very good Additional Information Question Title * 17. Would you like someone to contact you in relation to your feedback? Yes No Question Title * 18. Is there any further information you would like to provide? Question Title * 19. Did the staff provide you with the information on how to make a complaint? Yes No Question Title * 20. Contact Information (optional) Name City/Town ZIP/Postal Code Email Address Phone Number Click here when completed