Complementary Therapy Evaluation

Thank you for taking a few minutes to complete the following evaluation form. Your feedback will help us get a better understanding of whether complementary therapies are helpful and if so why

Please note the form is better viewed on a tablet or PC/Laptop rather than a Mobile device.

Complementary Therapies Evaluation Form

Thank you for taking the time to complete our evaluation form for your recent complementary therapy sessions. It is very important that you enter the unique Therapy evaluation ID we sent you via email in the field below, to help us log your form correctly.

Therapy evaluation ID

Please use the unique Therapy ID sent to you in our email. Please use the format "T-000001"

Personal details

First Name

Last Name

Contact Phone

Whichever is your preferred number

Contact Email

Complementary Therapy details

Type of Complementary Therapy

Date of first session

Date of final session

Question 1

Below is a list of possible after effects. Please select your score after 10 sessions of complementary therapy

Other possible after effects

Question 2

Did Complementary therapy meet your expectations?

YesNoExceeded

Can you please explain how the complementary therapy meet your expectations

Question 3

Would you consider continuing to use complementary therapies in the future?

Sharing your story

From time to time we appreciate being able to share the benefit you have felt from counselling after meningitis. Would you be willing to share your experience, eg case study, evaluation in our publications and on social media

Yes I give permission

Contact Information

	N/A	1 (mild)	2	3	4	5 (severe)
Exhaustion
Headaches
Memory loss
Anxiety
Depression
Dizzy/balance problems
Hearing difficulties
Other (please give details)