Name *

First Name

Last Name

Exit Date *

MM

DD

YYYY

Date for follow up *

MM

DD

YYYY

I've been feeling optimistic about the future

None of the time

Rarely

Some of the time

Often

All of the time

I've been feeling useful

None of the time

Rarely

Some of the time

Often

All of the time

I've been feeling relaxed

None of the time

Rarely

Some of the time

Often

All of the time

I've been dealing with problems well

None of the time

Rarely

Some of the time

Often

All of the time

I've been thinking clearly

None of the time

Rarely

Some of the time

Often

All of the time

I've been feeling close to other people

None of the time

Rarely

Some of the time

Often

All of the time

I've been able to make up my own mind about things

None of the time

Rarely

Some of the time

Often

All of the time

Has the service reduced your need to visit the GP?

None of the time

Rarely

Some of time time

Often

All of the time

I would recommend the service to a friend or family member or someone in a similar situation

None of the time

Rarely

Some of time time

Often

All of the time

I have achieved one of the meaningful goals in my support/wellbeing plan

None of the time

Rarely

Some of time time

Often

All of the time

There have been improvements for me in one or more of the personal goals I needed support with

None of the time

Rarely

Some of time time

Often

All of the time

I feel that I had choice and control (service/venue, listened to and planned support together)

None of the time

Rarely

Some of time time

Often

All of the time

I was involved as much as I wanted to be in developing my support/wellbeing plan and goals

None of the time

Rarely

Some of time time

Often

All of the time