My issue(s) is/are: Please provide full details such as who experienced the issue, where, when, who else was involved. *
Enter your feedback here.
Tell us briefly what was good, what wasn’t so good about your experience and how it could be improved *
In relation to this experience, please tick the box that best describes you *
- Select - Service User Carer Relative Staff Member Visitor Other
The first part of your postcode i.e TR15 *
Age *
- Select - Under 16 16-17 18-24 25-49 50-64 65-79 80+ Prefer not to say
Ethnicity *
- Select - Arab Bangladeshi Caribbean Chinese White British White Cornish Gypsy or Irish Traveller Indian Asian British African Black British Any other Asian background Any other Black background Any other Mixed/Multiple ethnic background Any other White background Prefer not to say Other
Sexual Orientation *
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Marital Status *
- Select - Single Married Divorced Widowed Civil Partnership Prefer not to say Other
Disability *
- Select - Yes No Prefer not to say
Religion *
- Select - Buddhist Jewish Christian Muslim Hindu Sikh None Prefer not to say Other
Gender *
- Select - Female Male Non Binary Prefer not to say Other
If you answered ‘other’ to any of the previous questions, please provide further details in the freeform box below
Does your gender identity match your sex as registered at birth? *
- Select - Yes No Prefer not to say
Phone number
Please tell us where you heard about Healthwatch Cornwall e.g. press *
Your story could help to raise awareness and encourage others to speak out. Healthwatch Cornwall would like to use your story as a case study or in a relevant press release. Please indicate if you are happy for us to do this. If yes, we may need to call/email you for more information. Thank you. *
My story can be fed back as written/shared with Healthwatch Cornwall, without passing on my name and/or contact details (although I understand it is not possible to guarantee complete anonymity, due to the detail of events/information provided) *
My story can be told as written/shared with Healthwatch Cornwall, with consent to provide my name/Personal Identifiable Information to the service provider, should they wish to investigate my experience further (we will not routinely share your contact details) *
