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Client Feedback Form
We are very keen to improve the service we provide to individuals wanting to stop smoking. Your views about this are very important to us and will be treated in the strictest confidence. Please answer the following questions as honestly as you can. The results of this survey will be used for evaluation and to improve services for the future.
Please note an email account is NOT REQUIRED to be able to complete this survey.
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* Indicates required question
Overall, how satisfied are you with the service you received?
*
Very Unsatisfied
1
2
3
4
5
Very Satisfied
Would you recommend our service to your family/friends?
*
Yes
No
Unsure
If you started smoking again would you return to the service for help to stop?
*
Yes
No
Unsure
Was it easy to contact the stop smoking service?
*
Yes
No
Unsure
Were you offered a range of times and venues to attend?
*
Yes
No
Usure
How would you rate the support you received from your advisor?
*
Very Unhelpful
1
2
3
4
5
Very Helpful
How long did you have to wait for your first appointment?
*
Same day
Same week
Less than 2 weeks
2-4 weeks
More than 4 weeks
Was it helpful having your carbon monoxide (CO) reading done (blowing into portable machine)?
*
Yes
No
CO not taken
Were you offered a choice of NRT/medication? (Patches, gum, mouth spray, inhaler, strips, lozenges, etc.)
*
Yes
No
Were you offered a vape/e-cig
*
Yes (but never received)
Yes (and received)
No
Where did you receive your stop smoking support?
*
Stop Smoking Service
Vape Shop
Was it easy to obtain your medication?
*
Yes
No
How did you hear about the Stop Smoking Service?
*
Smokefree Hampshire Website & Social Media (Facebook & Twitter)
Marketing Materials (postcards, leaflets & posters)
GP / Pharmacy / Other Healthcare Professional
Outreach Team (events / bus)
Family & Friends
Used Service Before
Other
Do you have any further comments you would like to add?
Please complete the contact details section below if you would like to be contacted by a member of the Smokefree Hampshire team.
Your answer
Please use the space below to write an optional quote about your experience of stopping smoking and the Smokefree Hampshire service.
Please note by submitting this information you give consent for Smokefree Hampshire and Solutions 4 Health to use your quote on social media, on their website and on other promotional materials
Your answer
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