Feedback form

If you have recently visited one of our services for sexual health advice and/or treatment we would like to hear about your experience through our online feedback form. This will only take a few minutes of your time.

You can complete this feedback form without telling us who you are.  However if you’d like to know what we have done as a result of your comments, then we will need you to provide your name and how we can contact you in the box below. 

Your information will be held by NHS Wakefield District and MadebyPi so that we can contact/update you about the comments you have made. We won’t give your information to any other party unless required to do so by law.  For more info on how your information is used, how we keep it secure, and your rights to see information we hold on you please contact Hakeem Legge on his e-mail Hakeem.Legge@wdpct.nhs.uk

Your age 12 and under 13 to 16 17 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 71 to 80 81 and over

Gender Male Female Transgender

Ethnicity White - British or mixed British White - Irish White - Other White background Mixed - White and Black Caribbean Mixed - White and Black African Mixed - White and Asian Mixed - Other Mixed background Asian or Asian British - Indian or British Indian Asian or Asian British - Pakistani or British Pakistani Asian or Asian British - Bangladeshi or British Bangladeshi Asian or Asian British - Other Asian background Black or Black British - Caribbean Black or Black British - African Black or Black British - Other Black background Other Ethnic Groups - Chinese Other Ethnic Groups - Other Other Ethnic Groups - Ethnic category not stated e.g. Black British/White British/Chinese

Where did you go? add the name and place of the service you visited

Date of visit 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 2010 2011 2012 2013

Optional - if you would like us to get in touch about your feedback then please provide contact details below.

Your Name

Your Phone number

Your Email address

Your address

Was finding the service easy?

YesNo

Please tell us why...

Was getting into the building easy?

YesNo

Please tell us why...

Were the opening times OK for you?

YesNo

Was there any information on display to say that you can come with a friend and without a parent or carer?

YesNo

Do you think the service was easy for people with a disability to use (physical or learning)?

YesNo

If you need some extra help or support, was the service able to provide this?

YesNo

Please tell us why...

Do you trust workers to keep your personal details private?

YesNo

Did you feel okay to ask questions if you weren't sure about something?

YesNo

Did you see a poster about confidentiality on display?

YesNo

Do you think the service is safe and suitable for young people?

YesNo

Were the workers friendly and welcoming?

YesNo

When you arrived, could you speak to the staff member about why you were there without being overheard?

YesNo

Do you know how to make a comment, complaint or suggestion about the service?

YesNo

Do you think that workers will act on feedback about the service?

YesNo

Was there any information on display about other issues e.g. sexuality, mental health?

YesNo

If you asked about pregnancy options, abortions, sexual health or
contraception, did the staff member try to make you feel comfortable, relaxed and
not embarrassed?

YesNo

Was information on display about other health services?

YesNo

Would you be happy using the service again?

YesNo

Please tell us why...

Would you encourage your friends to use the service?

YesNo

Please tell us why...

Overall how did you feel about your experience of using the service?
Rate on scale of 1 to 5, with 5 as excellent

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Please add any other comments here