CHIRT – Patient and Carer Survey

Name* (optional)

*You do not have to give us your name unless you want to. Any information you do give us will be stored confidentially and in line with NHS guidelines.

Are you:

Someone with a head injuryCarer for someone with a head injury

You were recently seen by a member of the team. We would like you to tell us what you think about the service. This is so we know what we are doing well and where we could make changes.

1) Where were your appointments with the service?

At homeAt hospitalBoth
Comments:

2) We would like to know what you think about your appointments with the team.
Please answer Yes/No to the following questions:

The appointment times suited me

YesNo

The places I attended for my appointments suited me

YesNo

I was happy with how long I had to wait to see someone for my first appointment

YesNo

Comments:

3) We would like to know what you think about the support you have had from the team.

Please tick one box on each line.	Strongly Agree	Agree	Neither	Disagree	Strongly Disagree
The support from the team has helped me to understand the effects of the brain injury better	Strongly Agree	Agree	Neither	Disagree	Strongly Disagree
The support from the team has helped me to manage the effects of the brain injury better	Strongly Agree	Agree	Neither	Disagree	Strongly Disagree
I had the number of rehabilitation sessions I feel I needed	Strongly Agree	Agree	Neither	Disagree	Strongly Disagree

Comments:

4) Please tell us about anything you feel is particularly good about the Head Injury Team service:
5) Please tell us about anything you feel the Head Injury Team service could change or improve.

If you would like someone from the team to contact you about what you have told us please tick this box and make sure you have given us your name and contact details:

Thank You