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

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 are you involved in?

Flexible Assertive 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 Service Worker (IGSW) Eating Disorders Housing Skills for Safer Living Self Help 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

Thank you for your participation and your feedback.

Send me a copy of my responses

Email address

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