Participant Closing Questionnaire

Participant Closing Questionnaire
Is this form being completed over the phone?

yesno
Guidance when completing paperwork by phone

- Confirm you are speaking to the right person

- Explain the information clearly and as written

- Check for understanding (you could ask the participant to explain what you've said, but in their own words)

- Offer to repeat anything at any time

- Obtain explicit verbal consent for any declarations (the participant needs to say 'yes, I consent' before you select the declaration option)
Your name (COVEY participant):

First NameLast Name
When did you begin with COVEY?

DayMonthYear
Date
What are some of your favourite memories during your time with COVEY?

Thinking about your time with COVEY, from when you were first referred to now, how would you rate the following things (1 star = not at all, 4 stars = a lot):

	*	**	***	****
COVEY helped me have fun
COVEY helped me learn new skills
COVEY has given me confidence to try new things
COVEY made me feel better about myself
COVEY made me feel safe and secure
COVEY helped my confidence in meeting new people
COVEY helped me make friendships
COVEY has given me positive role models
COVEY has given me confidence to express my views and feelings
COVEY has given me confidence to make choices

Has your time at COVEY made a difference to you?

YesNo
What are the main differences you've noticed about yourself since joining COVEY?
Has your time at COVEY made a difference to your family?

YesNo
What are the main differences you've noticed about your family since you joined COVEY?
Is there anything you'd like to share that COVEY does well? e.g. relationships, activities, organisation, communication, opportunities

YesNo
What do you think COVEY could does well?
Is there anything you'd like to share that COVEY could have done better? e.g. communication, activities, organisation, processes

YesNo
What do you think COVEY could do better?
If someone asked you what it's like to be supported by COVEY, what would you tell them?
Your declaration (by phone)

The above information is correctThe above information is not correct
Participant's Signature:

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The name of the COVEY Team Member completing this form:

First NameLast Name
The name of the COVEY Team Member completing this form over the phone:

First NameLast Name
COVEY Team Member's Signature:

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COVEY Team Member's Signature completing this form over the phone:

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Name of Parent/Carer/Guardian of participant (if applicable)

First NameLast Name
Parent/Carer/Guardian of participant's signature (if applicable):

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Date completed:

DayMonthYear
Date
Date completed by phone:

DayMonthYear
Date
Should be Empty: