* 1. What is your understanding of the remit of the Mental Health Crisis Response and Home Treatment Service?

* 2. Have you received written information from the service that includes:

  Yes No
A clear description of the service
Age range that the service accepts
Who can refer
How to make a referral

* 3. When did you last refer someone to the service?

* 4. Please answer the questions based on the last referral you made. There is space on the form for telling us about any different experiences you have had.

What was the primary reason for the referral?

* 5. When did you make the referral? (tick all that apply)

* 6. Was your referral accepted?

* 7. If your referral was not accepted by the service, what alternative help and support was provided?

* 8. If your referral was not accepted by the service, please go to Question 13. Otherwise please continue.

If your referral was accepted, were you included in the initial assessment of the individual’s needs?

* 9. How long did it take before the service arrived/responded to undertake an assessment of the individual’s needs?

* 10. What feedback did you receive from the service following the initial assessment?

* 11. Were you involved in developing the individual’s Care Plan?

* 12. Were you involved in the individuals Discharge Planning Arrangements?

* 13. Have you made referrals to this service more than once in the last 12 months?

* 14. If 'yes' to question 13, is the experience recorded in this survey typical of your experience?

* 15. If you answered 'no' to question 14, please use the space below to tell us about a different experience:

* 16. What is good about the service?

* 17. Overall, what could be improved?

* 18. Overall, was your experience of making a referral to the service?

  Very poor Poor Ok Good Excellent
Helpfulness of the service staff
Feedback from the service
Involvement in the process
Overall experience

* 19. Please give details of your organisation and team.

T