Sussex Experience Form (Easy Read version)

Team
Green happy face Neutral Sad face

We want to know what it was like for you.

Me

Who are you?

Service user
Carer
Service user Carer
Team

Who did you see?

Question 1
Team
Green happy face
Neutral
Sad face
Person shrugging
Person speaking giving their feedback

Question 2
Person listening to another person Two people pointing at a board

Did the service listen to what you think about your care?
Did the service do something about what you said?

Green happy face
Sad face
Neutral
Person shrugging
Person speaking giving their feedback

Question 3
Care plan booklet

Do you have a care plan?

Green yes tick
Red no cross
Person shrugging
Person speaking giving their feedback

Question 4
Multiple calendars Group with person holding bare review booklet

Have you had a care review meeting in the last 12 months?

Green yes tick
Red no cross
Person shrugging
Person speaking giving their feedback

Question 5
Two people standing with a board

Do you know what will happen next with your care and treatment?

Green yes tick
Red no cross
Person shrugging
Person speaking giving their feedback

Question 6
Person in crisis Person calling the NHS out of hours

If you had a crisis out of office hours, for example at the weekend or at night, do you know who to contact in the NHS?

Green yes tick
Red no cross
Person shrugging
Person speaking giving their feedback

Question 7
Person speaking giving their feedback

Person receiving help

If you need help to fill in this form ask someone you trust