Questionaire

Title:

Please Select Mr. Mrs. Miss Ms.

Name:*

Address:

Tel/Fax No:

Postcode

Email Address:*

Which Local Authority do you live in?

What is your neurological condition or injury?

In what year did you first have contact with health services for this condition/injury?

Do you now (this year 2010) see anyone at the hospital for this condition/injury?

Please Select Yes No

If YES please give details of Who & Where

Do you now (this year 2010) see anyone in the community for this condition/injury?

Please Select Yes No

If YES please give details of Who & Where

Have you ever been in a rehabilitation ward or residential unit?

Please Select Yes No

If YES please give details of Ward/Unit:

For how long?

Wks:

Year:

Do you receive any services from or through
Social Services?

Please Select Yes No

If YES please give details

Did you feel that you were treated as an individual ie received ‘a person-centred service’ in your contacts with the
people who treated you or provided
necessary services? Please describe
your experiences

Have you ever been invited to give your views about services?

Please Select Yes No

What changes are you most keen to see?

How satisfied are you overall with your
contacts with:(tick check box)

Health Services:

Satisfied

Mixed Feelings

Dissatisfied

Social Services:

Satisfied

Mixed Feelings

Dissatisfied

Any other comments

Would you like your contact details (as above) to be included in our records, so that we can keep you in touch with relevant developments, including opportunities to meet other people in similar situations or to put your views to the people who plan and provide services?

Please Select Yes No

Do you belong to a related voluntary group either nationally or locally? (tick check box)

Yes

No

If ‘Yes’, please give the name and contact number(s) for the group

Any other comments