Safe Space Emergency Department Feedback Form

This questionnaire is in relation to your recent visit to A&E, where you were seen by a Mind HFEH Safe Space Practitioner.

Please answer the following questions so we can understand your experience and recommendations on the service.

Thank you for taking the time to give feedback, it helps us improve our service.

Full Name *

First

Last

Date of Birth *

Which A&E Department did you visit? *Charing Cross HospitalSt Bernard’s HospitalWest Middlesex Hospital

Were you treated with respect and dignity at Safe Space Emergency Department?

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1 star for no, 5 for absolutely

Were you heard and listened to at Safe Space Emergency Department?

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1 star for no, 5 for absolutely

Did we provide tools to help you work through and manage this crisis?YesNo

If yes, what were they, and were they helpful?

Would you recommend the service?YesNo

What did we do well?

What can we improve on?

How would you rate your current level of crisis? (1 being very low crisis, 5 being very high crisis)

Selected Value: 1

1: Very low crisis. 2: Low crisis. 3: Neutral/No change. 4: High crisis. 5: Very high crisis.

How would you rate your current mood? (1 being great, 5 absolutely horrible)

Selected Value: 1

1: Great. 2: Good. 3: Fine. 4: Not good. 5: Absolutely horrible.

Have you been to A&E since attending Safe Space? *NoYes

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