Feedback Form Are you:*Supported by usThe relative or friend of someone supported by usAn external professionalSupported by usYour name and address*I want to tell you my name and where I liveI don’t want to tell you my name or where I liveThis will help us to look at what you’re unhappy about in more detail and we can let you know what we find out. If you don't want to tell us your name or where you live we will look at the way we work as a company, but we might not be able to do anything about what’s making you unhappy. Please tell us your name First Last I would like you to contact me by* Telephone Email Post Telephone*Email* Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Do you want to:*Tell us about something great!Tell us about something you’re unhappy aboutTell us about something great!Do you want to tell us something about:*Your houseYour staffSomeone you live withSomething elseYour houseTell us what it is about your house that is great?*Your staffIs it about:*Your whole teamCertain person / peoplePlease tell us more*The name of the staff / what they have done that is great etcSomeone you live withPlease tell us more*Something elseIs it about:*A holiday you have been onAn activity you have doneSomething you have done for the first timeA new job you haveSomething elseWhat is it?*How did it make you feel?*What is your new job?*How does it make you feel?*Please tell us more*Tell us about something you're unhappy aboutAre you unhappy about:*Your houseYour staffSomeone you live withSomething elseYour houseWhat is wrong with your house?* Something is broken Something needs decorating The garden needs doing Something else Please tell us more:*Your staffTell us if you’re unhappy about:*All your staff teamJust some of your teamA certain personPlease tell us who*Are you unhappy about:* The way you are spoken to Not getting all your support hours Not getting the support you need Not getting the support you want to do the activities you want to do Staff using their mobile phone whilst supporting you Staff sitting in the office when they should be supporting you Staff talking to each other and ignoring you Staff using your things without asking you I don’t feel safe with my staff Something else Please tell us more:*Someone you live withIs the person you live with:*Too noisyComing into your roomShouting at youHitting youThreatening youTaking things that belong to youAsking you to do things you don’t want toSomething elseTell us more*Tell us what they are saying*What have they taken?*What are they asking you to do?*If you’ve told someone about this, who did you tell?Something else you're unhappy withIf it’s something else you’re unhappy with:*I don’t feel safeI don’t have the chance to choose who supports meI never know who is going to support meI want to live somewhere elseI need support with something outside of Eden FuturesCan you tell us why you don’t feel safe?*Can you tell us why you want to move?*Can you tell us any more?*If you’ve told someone about this, who did you tell?I need support with something outside Eden FuturesWhat do you need help with?*Your GPThe hospitalA family memberA friendThe day service you go toThe place you workA strangerSomething elseTell us how you’d like us to help you*Tell us what it is and how you’d like us to help you*The relative or friend of someone supported by usAre you:*A relativeA friendName and contact details of the person completing the form:*Who is the person you are related to or a friend of and where do they live?*Do you want to leave a:*ComplimentComplaintPlease leave details of your compliment:*Give us as much information as possible so that we can make sure it’s passed onto the right person / people.Please leave details of your complaint:*Give us as much information as possible so that we can make sure it’s passed onto the right person / people.Have you told anyone about your complaint before? If so, who did you tell?An external professionalPlease tell us your name / contact details / job role*Do you want to leave a:*ComplimentComplaintPlease leave details of your compliment:*Give us as much information as possible so that we can make sure it’s passed onto the right person / people.Please leave details of your complaint:*Give us as much information as possible so that we can make sure it’s passed onto the right person / people.Have you told anyone about your complaint before? If so, who did you tell?CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
