Anam Cara Colac Community Survey Question Title * 1. What region do live in? Colac Otway Shire Corangamite Shire Surf Coast Shire Melbourne Metropolitan Golden Plains Shire Other Other (please specify) Question Title * 2. What age group do you fit into? Under 18 18-24 25-34 35-44 45-54 55-64 65+ Other (please specify) Question Title * 3. Do you or a member of your family have a chronic life limiting illness? Yes No Question Title * 4. Have you heard of Anam Cara House Colac? Yes No Question Title * 5. What services do you think Anam Cara Colac provides? Short stay respite for people with chronic life limiting illnesses End of life care In home respite for people who are nearing the end of life Day respite Illness specific support groups Grief and Bereavement counselling for people using our services and their families Post acute care for people who need a little extra recovery time to get home after surgery or illness All of the above Question Title * 6. Have you or a member of your family used any of our services? Yes No Question Title * 7. If so, could you state which one? Question Title * 8. If yes, how rate your or their experience at Anam Cara House Colac? Excellent Very Good Good Neutral Poor Please see the rating scale Please see the rating scale Excellent Please see the rating scale Very Good Please see the rating scale Good Please see the rating scale Neutral Please see the rating scale Poor Other (please specify) Question Title * 9. What do you think best describes an advanced care directive? It empowers you to make clear legal arrangements for your future health care. It describes how you would like your end of life care to be. It allows you to document your preferred future living arrangements and other personal matters. Allows you to appoint one or more decision makers to make decisions on your behalf if you are unable to do so in the future. All of the above Question Title * 10. Have you completed an Advance Care Directive? Yes No Question Title * 11. If no, if you were offered help to complete an Advance Care Directive would you utilize it? Yes No Question Title * 12. Anam Cara Colac will be facilitating a Bereavement Support Group next year. If you have experienced a bereavement and were offered access to support would you utilize it? Yes No Unsure Question Title * 13. If yes, what type of bereavement support would you feel would be most useful to you? One on one support with a counselling psychologist A group, peer-led support group which maybe a social group, a walking group, or activity group as determined by the participants Structured information about bereavement and grief Other (please specify) Question Title * 14. This year we have held a number of information events: please tick if you attended any of them. Please see the comment box if you want toadd any feedback. Palliative Care Week with guests speakers from Shannon's Bridge in Creswick Carers and Chronic Illness information sessions 4 day program Dying to know day- Dr Charlie Corke Other (please specify) Question Title * 15. If you did attend one or more of these sessions would you please rate each one according to your experience of the event. Poor Neutral Good Very Good Excellent Palliative Care Week Open Day Palliative Care Week Open Day Poor Palliative Care Week Open Day Neutral Palliative Care Week Open Day Good Palliative Care Week Open Day Very Good Palliative Care Week Open Day Excellent Carers and Chronic Illness Information sessions 4 day program Carers and Chronic Illness Information sessions 4 day program Poor Carers and Chronic Illness Information sessions 4 day program Neutral Carers and Chronic Illness Information sessions 4 day program Good Carers and Chronic Illness Information sessions 4 day program Very Good Carers and Chronic Illness Information sessions 4 day program Excellent Dying to Know Day - Dr Charlie Corke Dying to Know Day - Dr Charlie Corke Poor Dying to Know Day - Dr Charlie Corke Neutral Dying to Know Day - Dr Charlie Corke Good Dying to Know Day - Dr Charlie Corke Very Good Dying to Know Day - Dr Charlie Corke Excellent Question Title * 16. Do you have any suggestions for other health information events in the future? Please comment below. Yes No Other (please specify) Done
