Client Experience Survey
Client Experience Feedback Form
Dear Client:
CMHA Waterloo Wellington is committed to providing the highest possible quality of care to our clients. In order to help us do that, we are asking you to complete this survey about your experiences here so we can continue to do what we do well and to make improvements where needed.
Your name will not appear anywhere on the survey, and your answers are completely anonymous and confidential. Results will be reported only at a program or organization level, and no one involved in your care will know how you responded.
While we hope that you will give us your feedback, whether you do the survey is entirely your decision. Saying no will not affect your care in any way. You can also skip any question you don’t want to answer and you can stop doing this survey at any time.
The survey will take about 15 minutes of your time. For each item, check the box that most accurately reflects your experience. Please answer all questions for the program or service where you currently receive support.
Thank you.
Today's date
I was able to get help when I needed it.
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
Appointments were available at times that were good for me.
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
Seeing a worker quickly helped me to address my needs and to set goals.
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
I felt heard, understood, and respected.
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
My worker focused on what was important to me.
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
My worker focused on what I needed help with.
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
My beliefs about health and well-being are considered as part of the help (services) that I received.
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
I am involved as much as I want in decisions about my treatment or service.
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
My family/others are involved in my treatment (service) when I choose.
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
Information is provided in a language or way I can easily understand.
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
I feel safe in bringing forward concerns.
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
I understand my care plan.
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
How much have the services you have received helped to make things better for you?
Please rate your knowledge/experience.
Knowledge about mental health, addiction, and developmental issues
Much Better
A Little Better
No Change
Worse
Much Worse
Progress towards my goals
Much Better
A Little Better
No Change
Worse
Much Worse
Ability to cope with distress
Much Better
A Little Better
No Change
Worse
Much Worse
My health and well-being
Much Better
A Little Better
No Change
Worse
Much Worse
My symptom(s)
Much Better
A Little Better
No Change
Worse
Much Worse
My quality of life
Much Better
A Little Better
No Change
Worse
Much Worse
Which program(s) are you involved in?
Flexible Assertive Community Treatment Team (FACT)
Support Coordination
Counselling and Treatment
Dialectical Behaviour Therapy (DBT)
1st Step
Psychiatry
Mental Health and Justice
Specialized Geriatric Services (SGS)
Intensive Geriatric Services (IGSW)
Eating Disorders
Self Help Services
Housing
Employment Services
Other
Which location do you attend?
Guelph - Waterloo Ave
Guelph - Wyndham St
Guelph - Silvercreek
Fergus
Mount Forest
Kitchener - King St
Kitchener - Weber St
Waterloo - Blue Springs
Cambridge - Wellington Ave
Cambridge - Langs
Other
Comments
Thank you for your participation and your feedback.
Send me a copy of my responses
Email address
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