Client Satisfaction Survey Form

You are very important to us at Blue Ridge Speech & Hearing Center, and we work hard to insure that you are satisfied with your experience here. Please take a moment to share your thoughts and comments with us so that we can respond with any necessary improvements.

		Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree	N/A Does Not Apply
1.	You were able to schedule an appointment in a reasonable period of time.
2.	You were greeted / acknowledged when signing in.
3.	You were seen on time for your scheduled appointment.
4.	You feel that you have benefited from the services received here.
5.	Front office staff who served you were courteous and pleasant.
6.	BRSH Professional staff who served you were courteous and pleasant.
7.	BRSH Staff respected your special needs (age, culture, education, handicapping condition, eyesight, hearing…)
8.	We included your family or other persons important to you in the services we provided.
9.	Staff members were prepared and organized.
10.	Staff members were experienced and knowledgeable.
11.	Our services were explained to you in a way that you could understand.
12.	The environment was clean and pleasant.
13.	The environment was quiet and distraction free.
14.	The length and frequency of your service program was appropriate.
15.	The nature of your problem and our recommendations were adequately explained.
16.	We planned ahead and provided sufficient instruction and education to help you retain your skills after your program ended.
17.	Overall, the program services were satisfactory.
18.	You would come back toe BRSH if you need our help again.
19.	You would recommend us to others.

Services Requested

Please select the hours of service time that would be best for you:
	Monday – Friday 8-9 9-12 12-1 1-3 4-5 5-7
	Saturday 8-9 9-12 1-4

Please check all of the services you received (Required):
	Audiology / Hearing Services Speech – Language Services Occupational Therapy Services

Comments

Please provide additional information which might help us provide clients with outstanding service.

Survey Participant Information

The person completing this form is:
	Client Parent Spouse Other Family Member Primary Care Giver Other. Please explain:

Name: (Optional)