Home Care Feedback Form
Please answer the first
4 questions
from a scale of Strongly Disagree to Strongly Agree.
Strongly Disagree (1), Slightly Disagree (2), Neutral (3), Slightly Agree (4) & Strongly Agree (5)
1. The content of the care was useful and interesting
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
2. The care well organised
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
3. The services where they adequate?
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
4. Did the services meet your expectation?
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
Please answer the next
2 questions
from a scale of Poor to Excellent. Poor (1), Average (2), Good (3) & Excellent (4)
5. What did you think of our external services?
Poor
1
2
3
Excellent
4
1 is Poor, 4 is Excellent
6. What did you think of the carer who came?
Poor
1
2
3
Excellent
4
1 is Poor, 4 is Excellent
7. Was adequate time provided for questions and discussion?
Yes
No
8. Do you think you can help with improving the care?
Yes
No
9. What aspects of the care could we improve?
10. What else would you like to see added to your services?
Submit
Should be Empty: