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    Community Head Injury Rehabilitation Team (CHIRT)


    Patient and Carer Survey: Your Voice Matters



    *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.

    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.

    At homeAt hospitalBoth

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

    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


    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