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Changing Lives Feedback Form

To help Crisis Changing Lives assist homeless people we ask all grant recipients to complete a feedback form six months and twelve months after receiving their grant. Please fill out the following form and submit it as soon as possible. Alternatively you can download the feedback form and return it to us.

(If you are a support worker please either contact the grant recipient or fill this form out to the best of your knowledge).

Private and confidential

Grant recipient details

First name *

Surname *

Education and Qualifications

1. Are you currently on a course?

Yes
No

What course are you on?

2. Have you completed any courses or course modules since your award?
If you did, please list them below

Yes
No

Course/module:

Date completed

/ /

Course/module:

Date completed

/ /

Course/module:

Date completed

/ /

3. Did you get any qualifications?

Yes
No

If yes, what qualification did you get?

4. Since the award, did you learn new skills that could help at work?

Yes
No

5. What kind of skills do you have that you may not have had before you did your course?
(e.g. computer skills, business skills, managing my time, organising my work, communicating, listening to people, looking for work, technical skills related to my career choice, etc) Please list the new skills you now have:

Volunteering and Employment

6. Have you done work placements/voluntary work since the award?

Yes
No

What did you do?

Start date

/ /

End date

/ /

Was this a part of your course?

Yes
No

7. Have you done any paid work since receiving your grant?

Yes
No

What did you do?

Are you still working?

Yes
No

Work start date

/ /

Work end date

/ /

Social and emotional well-being

8. Have you met any new friends or contacts on your course, at work or in self employment since you got your grant?

Yes
No

9. How do you feel your self esteem and confidence has changed in the last 6 months?

Decreased
No change
Improved some
Improved a lot

Comments on your self esteem and confidence:

10. The award has hopefully helped you move towards your vocational goal. How is your motivation now to reach your goal?

Decreased
No change
Improved some
Improved a lot

Comments on your motivation

Your benefits

11. Have your benefits reduced as a result of paid work since the grant?
If yes, Please tick which benefits have reduced:

Yes
No

Job Seekers Allowance (JSA)

Income Support

Housing Benefit (HB)

Incapacity Benefit (IB)

Council Tax Benefit

Employment Support Allowance (ESA)

Other

Living situation

12. Have you changed your accommodation since you had your grant?

Yes
No

If yes, did your accommodation change because you needed less support?

Yes
No

If you have moved on, what type of housing do you now have?

Hostel
Housing association
Council flat/house
Flat supported housing
Privately rented
Other

Please state your current address:

Please give your contact telephone number:

Please give your email address:

Please match the below text. If you can not read the words, refresh the box or use the audio version.

* Denotes required field.

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Changing Lives Feedback Form

Private and confidential

Grant recipient details

Education and Qualifications

Volunteering and Employment

Social and emotional well-being

Your benefits

Living situation

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