One-to-one therapies feedback form

>One-to-one therapies feedback form
One-to-one therapies feedback form 2017-02-24T09:58:51+00:00

We are looking for feedback from anyone who has used our one-to-one services within the past 6 months. We would be incredibly grateful if you could take some time to fill in this feedback form. Any feedback you may have is invaluable to us as we look to develop our services and support our fundraising efforts by showing the difference our services make. Thank you.

Please indicate which of these one-to-one services you have used within the last 6 months excluding counselling and answer the corresponding questions:


1. Doctor's one-to-one
YesNo

Name of Penny Brohn Doctor seen (if known)

How well did this meet your needs: 1 - not at all, 5 - extremely well
12345

Please give an overall rating for this Doctor: 1 - poor, 5 - excellent
12345


2. Nutritional Therapist one-to-one
YesNo

Name of Therapist seen (if known)

How well did this meet your needs: 1 - not at all, 5 - extremely well
12345

Please give an overall rating for this Therapist: 1 - poor, 5 - excellent
12345


3. Healing and Applied Relaxation
YesNo

Name of Healer seen (if known)

How well did this meet your needs: 1 - not at all, 5 - extremely well
12345

Please give an overall rating for this Healer: 1 - poor, 5 - excellent
12345

4. Massage
YesNo

Name of Therapist seen (if known)

How well did this meet your needs: 1 - not at all, 5 - extremely well
12345

Please give an overall rating for this Therapist: 1 - poor, 5 - excellent
12345

5. Music therapy (Guided imagery with music)
YesNo

Name of Therapist seen (if known)

How well did this/these session(s) meet your needs: 1 - not at all, 5 - extremely well
12345

Please give an overall rating for this Therapist: 1 - poor, 5 - excellent
12345

6. Reflexology
YesNo

Name of Therapist seen (if known)

How well did this/these session(s) meet your needs: 1 - not at all, 5 - extremely well
12345

Please give an overall rating for this Therapist: 1 - poor, 5 - excellent
12345

7. Shiatsu
YesNo

Name of Practitioner seen (if known)

How well did this/these session(s) meet your needs: 1 - not at all, 5 - extremely well
12345

Please give an overall rating for this Practitioner: 1 - poor, 5 - excellent
12345

8. Please tell us what difference (if any) using the individual appointments made to you?

Please grade the different parts of our service

Your welcome at the centre: 1 - poor, 5 - excellent
12345

Availability of appointments: 1 - poor, 5 - excellent
12345

Ease of booking appointments: 1 - poor, 5 - excellent
12345

Is there anything that would make the service better for you?

Confidentiality & Data Protection
I agree that my data and information can be held, accessed and processed by Penny Brohn UK for the purposes of evaluation and research. I also agree that my data can be used anonymously in Penny Brohn UK promotional materials. I further understand that all personal data or information I provide to Penny Brohn UK will be kept confidential and that no identifiable personal data will be published, presented or shared with a third party, or made public, without my express consent. I understand that I may withdraw my consent to provide my data at any time without giving a reason. I also understand that my consent is conditional on Penny Brohn UK complying with its duties and obligations under the Data Protection Act (DPA) 1998.*
I agree to the aboveI do not agree to the above

Thank you for your help with this questionnaire. Your feedback is invaluable to us. If you have any questions or would like to know more, please contact research@pennybrohn.org.uk.