Customer Experience Monitor Your Details Who's filling in this form?* —Please choose an option—The person receiving supportThe person's family memberThe person's support workerAn advocate for the person Your first name* Your last name* Email address* First name of the person supported* Last name of the person supported* What's your feedback about?* —Please choose an option—AspirationsClinical supportCultural supportHome SupportPlanned Breaks - OvernightPlanned Breaks - School HolidayPlanned Breaks - After-schoolPlanned Breaks - Weekend DaySupported AccommodationSupported Independent Living/CiCLTransitions Your Feedback I trust you care for me* Select the face that matches how you feel about the statement 12345 I think you care for me* Agree or disagree? AgreeDisagree I think you are kind to me* Agree or disagree? AgreeDisagree I trust you* Agree or disagree? AgreeDisagree Comments Is there anything you'd like us to know? You help me live my best life* Select the face that matches how you feel about the statement 12345 You help me to be more independent* Agree or disagree? AgreeDisagree You help me to make my own decisions* Agree or disagree? AgreeDisagree You help me to feel included* Agree or disagree? AgreeDisagree Comments Is there anything you'd like us to know? You listen to me and understand my needs* Select the face that matches how you feel about the statement 12345 I think you are understanding* Agree or disagree? AgreeDisagree I think you listen* Agree or disagree? AgreeDisagree I think you are responsive to my needs* Agree or disagree? AgreeDisagree Comments Is there anything you'd like us to know? Your service is safe, timely and reliable* Select the face that matches how you feel about the statement 12345 I feel safe when I use this service* Agree or disagree? AgreeDisagree I'm not left waiting or rushed when I use this service* Agree or disagree? AgreeDisagree This service is reliable* Agree or disagree? AgreeDisagree Comments Is there anything you'd like us to know?
