Client Experience Survey

Hello Everyone!

We are asking for your help to evaluate our services and programs. We want to know what you think about how we are doing and what we could do better. We want your honest opinions.

Please note:

Your name does not appear on the questionnaire.
Your answers will be kept confidential.
Your specific answers will not be shared with the staff.
There will be no affect on the service you receive here if you decide not to answer these questions.

As you answer the questions, please keep in mind the programs and services you have received over the past year. Be sure to include the following:

Appointments with staff
Groups and workshops
Community garden, advisory groups, committees, action groups

I am completing this survey while attending:

Medical Clinic – PQ
Medical Clinic – South Nepean
Counselling
Children and Family Services
First Words/Infant Hearing/Blind-Low Vision
Employment Services
Pathways to Education
Youth Programs
Community House Program
ACTT
Other, please specify:

Service Location (e.g. Richmond Road, Barrhaven, Lincoln Fields, Community House, (name) School, (name) other agency, etc.)

For the questions below, please check the box under the “face” that shows your response. For example, if you “strongly agree”, check the box under the two smiley faces. For some questions, you may answer that you “Don’t Know” or that the question does not apply to you—“Not Applicable.”

1	Strongly Agree
2	Agree
3	Don't Agree or Disagree
4	Disagree
5	Strongly Disagree
?	Don’t Know
N/A	Not applicable

OVERALL

	1	2	3	4	5
1) Overall, I am satisfied with the programs and services provided by Pinecrest-Queensway Community Health Centre.
2) I would refer a family member or friend to Pinecrest-Queensway Community Health Centre.

Why or why not?

ACCESS

	1	2	3	4	5	?	N/A
3)I can get an appointment when I need one.
4)The staff help me get the services I need.
5)The programs and services are provided in a language that is comfortable for me.
6)The programs and services are sensitive to my culture.
7)The programs and services are delivered in a way that accommodates my disability.

COMMUNICATION

	1	2	3	4	5	?	N/A
8)The staff are easy to talk to and encourage me to ask questions.
9)The staff explain things in a way I can understand.
10)I know how to make a suggestion or complaint.
11)The staff are open to my suggestions or complaints.

QUALITY

	1	2	3	4	5	?	N/A
12)The staff give me information that I can use to improve my health and well-being.
13)I am asked to give input into the programs and services I use.
14)The programs and services are responsive to my needs.

IMPACT

	1	2	3	4	5	?	N/A
15)I feel my quality of life is better because of the programs and services I receive here.
16)The programs and services helped me with things I was worried about.
17)The programs and services have helped me improve my well-being.

18)What is our centre doing well?

19)How can we improve what we are doing?

ABOUT YOU

Finally, we would like to ask some questions about you.

Your answers will help us to understand the results of this survey so that we can better meet the needs of our clients/participants All of your answers will be confidential. Of course, if you don’t want to answer any or all of these questions you don’t have to. However, we would greatly appreciate any information you can give us.

20)How many years have you been receiving services from our organization?

Less than 3 months
3 to 6 months
6 to 12 months
12 to 24 months
2 to 5 years
5 to 10 years
10 or more years

21)What services have you used at Pinecrest-Queensway Community Health Centre?

Medical Clinic – PQ
Medical Clinic – South Nepean
Counselling
Children and Family Services
First Words/Infant Hearing/Blind-Low Vision
Employment Services
Pathways to Education
Community Services
ACTT
Other (please specify)

22)How would you rate your overall health now?

Excellent
Very Good
Good
Fair
Poor

23)What is your age?

12 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 and older

24)What is your cultural background?

25)Are you… ?

Male
Female
Transgendered
Other (please specify)

26)Do you identify as a member of the Gay Lesbian Bisexual Trans Queer and Questioning Sexual Orientation and Gender Identity Communities?

Yes
No
Don't Know

27)Do you require access to services in a language other than English or French?

Yes. Please specify the language
No

28)What is the highest grade or level of school that you completed?

Grade 8 or less
Some high school, but did not graduate
High school graduate
College/university diploma or degree
Other (please specify)
No

29)What is your household’s source of income?

No income
Social assistance
Retirement pension
Other pension
Employment income
Other income

30)What is your household income?

Less than $15,000
$15,000 to $19,999
$20,000 to $29,999
$30,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 and over

GENERAL QUESTIONS

	1	2	3	4	5
31)This survey gave me the chance to express my opinions.
32)The survey was about the right length.