Indicates required field Take five minutes to share your experiences NHS and social care staff are doing everything they can to keep us well during these challenging times, but there might be things that can be improved for you and your loved ones. Please take five minutes to share your story with us. To understand how we will use your information read the 'How we use this information' at the end of the page. Complete the survey 1. Choose the area of care you would like to tell us about? GP services Dentist Pharmacies Hospital inpatient (day treatment or overnight) Hospital outpatients' appointments Mental health support Social care eg care homes, and home care Accident and emergency/minor injury units Ambulances and paramedics NHS 111 Other issue/service (if other, please tell us which issue/service you are referring to) Please select the options that you'd like to talk to us about. You can pick more than one. If other, please tell us which issue/service you are referring to 2. Please tell us about you experience What went well? What could have been better? 3. Does your feedback apply to a specific service? If so, please tell us which ones(s). eg. the GP surgery name or hospital department 4. How easy was it to access the help and support you needed? Very good Good Neither good nor bad Poor Very poor N/A 5. How would you describe your experience of care? Good Neither good nor bad Poor I had a mixed experience Don't know/not sure Not applicable 6. In relation to this experience please select what best describes you I’m the person who received the care I’m providing this feedback on behalf of a friend or relative, or because I’m their carer Other Tell us a bit about you It would really help to know a little more about you so that we can better understand how people's experiences may differ. These questions are completely voluntary. 7. Please tell us your age - None -16 to 17 years18 to 24 years25 to 49 years50 to 64 years65 to 79 years80+Prefer not to say 8. Please tell us your gender 8. Please tell us your gender - None -WomanManNon-binaryPrefer not to sayPrefer to self-describe Enter other… 9. Is your gender identity the same as your sex recorded at birth? - None -YesNoPrefer not to say 10. Please tell us which sexual orientation you identify with 10. Please tell us which sexual orientation you identify with - None -AsexualBisexualGay manHeterosexual / StraightLesbian / Gay womanPansexualPrefer not to sayPrefer to self-describe Enter other… 11. Please select your ethnicity 11. Please select your ethnicity Any other ethnic groupArabAsian / Asian British: BangladeshiAsian / Asian British: ChineseAsian / Asian British: IndianAsian / Asian British: PakistaniAsian / Asian British: Any other Asian / Asian British backgroundBlack / Black British: AfricanBlack / Black British: CaribbeanBlack / Black British: Any other Black / Black British backgroundMixed / Multiple ethnic groups: Asian and WhiteMixed / Multiple ethnic groups: Black African and WhiteMixed / Multiple ethnic groups: Black Caribbean and WhiteMixed / Multiple ethnic groups: Any other Mixed / Multiple ethnic groups backgroundWhite: British / English / Northern Irish / Scottish / WelshWhite: IrishWhite: Gypsy, Traveller or Irish TravellerWhite: RomaWhite: Any other White backgroundPrefer not to sayAny other ethnic group Enter other… 12. Please select any of the following that apply to you I have a disability I have a long term condition I am a carer None of the above I prefer not to say 13. Which of the following best describes your financial status? I have more than enough for basic necessities, and a large amount of disposable income, that I can save or spend on extras or leisure I have more than enough for basic necessities, and a small amount of disposable income, that I can save or spend on extras or leisure I have just enough for basic necessities and little else I don’t have enough for basic necessities and sometimes run out of money I don't know/prefer not to say How we use this information The information you share with us helps us spot trends to identify areas for improvement. We may use quotes in our reports, but we will not use any information that will identify you. As well as your feedback, we also ask you to volunteer some personal information. This helps us to help us understand how different groups experience local health and social care services and supports our focus on improving equality, diversity and inclusion. If you are sharing information on behalf of another person, make sure that you have their permission to do so, or the information you do share should be anonymous. Find out more about how we handle your information in our privacy statement. Can we stay in touch? We'd love to tell your story and keep you updated about our work and the difference sharing your experiences with us can make. Using your story for media To promote our campaigns we use people's stories to show what needs to change. The media (newspapers, radio or TV) ask if we have people who can their story when we publish a press release about our research. Would you be happy for us to contact you about your experience for media purposes or to use your story as a case study in our material? We won’t pass on your name and contact details to the media without speaking to you first about what it involves. Please select I am happy to be contacted by Healthwatch Darlington to discuss whether my story could be a case study for a campaign or to be passed onto the media. I don't want to be contact by Healthwatch Darlington about being a case study for a campaign or for the media. Sign-up to our mailing list Sign-up to our mailing list to stay up to date with what people are telling us about health and social care, our advice and information, and our latest reports. You can unsubscribe from our mailing list at any time. Please select I want Healthwatch Darlington to email me about advice and information, latest news, research and updates. I do not want Healthwatch Darlington to email me about advice and information, latest news, research and updates. If yes, enter your name and email address. Name Email Submit Leave this field blank
