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Page 1 of 3
Client Satisfaction Survey Page 1
All fields marked with
*
are required.
*
Your name:
*
Your child's name:
Indicate the consistency with which therapists do the following
*
Arrive and depart on time for sessions.
Always (5/5 times)
Usually (4/5 times)
Sometimes (3/5 times)
Seldom (2/5 times)
Never (0/5 times)
*
Dress appropriately.
Always (5/5 times)
Usually (4/5 times)
Sometimes (3/5 times)
Seldom (2/5 times)
Never (0/5 times)
*
Communicate regarding the day's session.
Always (5/5 times)
Usually (4/5 times)
Sometimes (3/5 times)
Seldom (2/5 times)
Never (0/5 times)
*
Provide answers to questions or give directions on how to get answers to questions.
Always (5/5 times)
Usually (4/5 times)
Sometimes (3/5 times)
Seldom (2/5 times)
Never (0/5 times)
*
Have the skills to provide the services my child needs.
Always (5/5 times)
Usually (4/5 times)
Sometimes (3/5 times)
Seldom (2/5 times)
Never (0/5 times)
*
Are respectful in interacting with the family.
Always (5/5 times)
Usually (4/5 times)
Sometimes (3/5 times)
Seldom (2/5 times)
Never (0/5 times)
Indicate the consistency with which BCBA/BCaBA does the following.
*
Arrive and depart on time for sessions, meetings, parent training.
Always (5/5 times)
Usually (4/5 times)
Sometimes (3/5 times)
Seldom (2/5 times)
Never (0/5 times)
*
Dress appropriately
Always (5/5 times)
Usually (4/5 times)
Sometimes (3/5 times)
Seldom (2/5 times)
Never (0/5 times)
*
Communicate regarding the day's session.
Always (5/5 times)
Usually (4/5 times)
Sometimes (3/5 times)
Seldom (2/5 times)
Never (0/5 times)
*
Provide answers to questions or give directions on how to get answers to questions.
Always (5/5 times)
Usually (4/5 times)
Sometimes (3/5 times)
Seldom (2/5 times)
Never (0/5 times)
*
Have the skills to provide the services my child needs.
Always (5/5 times)
Usually (4/5 times)
Sometimes (3/5 times)
Seldom (2/5 times)
Never (0/5 times)
*
Are respectful in interacting with the family.
Always (5/5 times)
Usually (4/5 times)
Sometimes (3/5 times)
Seldom (2/5 times)
Never (0/5 times)
*
Incorporates things parents/family have identified as needs into program.
Always (5/5 times)
Usually (4/5 times)
Sometimes (3/5 times)
Seldom (2/5 times)
Never (0/5 times)
*
Asks for and listens to input from parents.
Always (5/5 times)
Usually (4/5 times)
Sometimes (3/5 times)
Seldom (2/5 times)
Never (0/5 times)
Page 2 of 3
Client Satisfaction Survey Page 2
All fields marked with
*
are required.
Based off of
{Company Name}
LLC services and interactions over the past 6 months rate the following:
*
Direct Therapy and individualized programming.
Very Dissatisfied, would or have recommended others not to use
{Company Name}
services
Dissatisfied- I have had more negative than positive experiences
Neutral- I have had positive and negative experiences with this
Satisfied- I have had more positive than negative experiences
Very Satisfied, would or have recommended others to use
{Company Name}
services
*
Parent training and Communication
Very Dissatisfied, would or have recommended others not to use
{Company Name}
services
Dissatisfied- I have had more negative than positive experiences
Neutral- I have had positive and negative experiences with this
Satisfied- I have had more positive than negative experiences
Very Satisfied, would or have recommended others to use
{Company Name}
services
*
Coordination with other service providers (School, speech, OT, PT, other) with consent
Very Dissatisfied, would or have recommended others not to use
{Company Name}
services
Dissatisfied- I have had more negative than positive experiences
Neutral- I have had positive and negative experiences with this
Satisfied- I have had more positive than negative experiences
Very Satisfied, would or have recommended others to use
{Company Name}
services
*
Scheduling
Very Dissatisfied, would or have recommended others not to use
{Company Name}
services
Dissatisfied- I have had more negative than positive experiences
Neutral- I have had positive and negative experiences with this
Satisfied- I have had more positive than negative experiences
Very Satisfied, would or have recommended others to use
{Company Name}
services
*
Range of services provided
Very Dissatisfied, would or have recommended others not to use
{Company Name}
services
Dissatisfied- I have had more negative than positive experiences
Neutral- I have had positive and negative experiences with this
Satisfied- I have had more positive than negative experiences
Very Satisfied, would or have recommended others to use
{Company Name}
services
*
Billing and Insurance support
Very Dissatisfied, would or have recommended others not to use
{Company Name}
services
Dissatisfied- I have had more negative than positive experiences
Neutral- I have had positive and negative experiences with this
Satisfied- I have had more positive than negative experiences
Very Satisfied, would or have recommended others to use
{Company Name}
services
*
Effectiveness of the services
Very Dissatisfied, would or have recommended others not to use
{Company Name}
services
Dissatisfied- I have had more negative than positive experiences
Neutral- I have had positive and negative experiences with this
Satisfied- I have had more positive than negative experiences
Very Satisfied, would or have recommended others to use
{Company Name}
services
*
Cost of services
Very Dissatisfied, would or have recommended others not to use
{Company Name}
services
Dissatisfied- I have had more negative than positive experiences
Neutral- I have had positive and negative experiences with this
Satisfied- I have had more positive than negative experiences
Very Satisfied, would or have recommended others to use
{Company Name}
services
*
My therapists
Very Dissatisfied, would or have recommended others not to use
{Company Name}
services
Dissatisfied- I have had more negative than positive experiences
Neutral- I have had positive and negative experiences with this
Satisfied- I have had more positive than negative experiences
Very Satisfied, would or have recommended others to use
{Company Name}
services
*
My BCBA/BCaBA
Very Dissatisfied, would or have recommended others not to use
{Company Name}
services
Dissatisfied- I have had more negative than positive experiences
Neutral- I have had positive and negative experiences with this
Satisfied- I have had more positive than negative experiences
Very Satisfied, would or have recommended others to use
{Company Name}
services
In the past 6 months of services with
{Company Name}
LLC I have observed the behaviors below to have changed in the following ways
*
Problem behavior with my child has
Decreased significantly
Decreased slightly
No change noticed
Increased slightly
Increased significantly
*
Language and communication use by my child has
Decreased significantly
Decreased slightly
No change noticed
Increased slightly
Increased significantly
*
Social awareness/interactions by my child has
Decreased significantly
Decreased slightly
No change noticed
Increased slightly
Increased significantly
*
Self-help skills and or independence has
Decreased significantly
Decreased slightly
No change noticed
Increased slightly
Increased significantly
*
My child's cooperation or listening to instructions has
Decreased significantly
Decreased slightly
No change noticed
Increased slightly
Increased significantly
Page 3 of 3
Client Satisfaction Survey Page 3
All fields marked with
*
are required.
Over the past 6 months parent training has
*
Given me valuable information on how to have more successful interactions with my child
No training on this has occurred
Disagree, training did not do this
Neutral- I have had positive and negative experiences with this
Agree, training helped in this way
*
Given me practice at using techniques to use with my child
No training on this has occurred
Disagree, training did not do this
Neutral- I have had positive and negative experiences with this
Agree, training helped in this way
*
Has helped me with how to respond to problem behavior with my child
No training on this has occurred
Disagree, training did not do this
Neutral- I have had positive and negative experiences with this
Agree, training helped in this way
*
Has helped me with how to increase communication and language use with my child
No training on this has occurred
Disagree, training did not do this
Neutral- I have had positive and negative experiences with this
Agree, training helped in this way
*
Has helped me with how to increase independent and self help skills with my child
No training on this has occurred
Disagree, training did not do this
Neutral- I have had positive and negative experiences with this
Agree, training helped in this way
*
Given me a way to track changes in my Childs behavior
No training on this has occurred
Disagree, training did not do this
Neutral- I have had positive and negative experiences with this
Agree, training helped in this way
Indicate how interested you are in the training areas below
*
How to handle Challenging Behavior
I have no interest in training on this topic
I might be interested in training on this topic
I would participate in an in home training on this topic
I would attend a training in home or in the office on this topic
I would pay to attend an in depth office training on this topic
*
Getting more communication from my child
I have no interest in training on this topic
I might be interested in training on this topic
I would participate in an in home training on this topic
I would attend a training in home or in the office on this topic
I would pay to attend an in depth office training on this topic
*
How to prevent problem behaviors
I have no interest in training on this topic
I might be interested in training on this topic
I would participate in an in home training on this topic
I would attend a training in home or in the office on this topic
I would pay to attend an in depth office training on this topic
*
Making certain times of day easier
I have no interest in training on this topic
I might be interested in training on this topic
I would participate in an in home training on this topic
I would attend a training in home or in the office on this topic
I would pay to attend an in depth office training on this topic
*
Increasing independence
I have no interest in training on this topic
I might be interested in training on this topic
I would participate in an in home training on this topic
I would attend a training in home or in the office on this topic
I would pay to attend an in depth office training on this topic
*
Increasing Age appropriate play skills
I have no interest in training on this topic
I might be interested in training on this topic
I would participate in an in home training on this topic
I would attend a training in home or in the office on this topic
I would pay to attend an in depth office training on this topic
*
Resources that are available in the area
I have no interest in training on this topic
I might be interested in training on this topic
I would participate in an in home training on this topic
I would attend a training in home or in the office on this topic
I would pay to attend an in depth office training on this topic
*
How to get the most out of your child's school experience
I have no interest in training on this topic
I might be interested in training on this topic
I would participate in an in home training on this topic
I would attend a training in home or in the office on this topic
I would pay to attend an in depth office training on this topic
*
Promoting teamwork between my Childs professionals
I have no interest in training on this topic
I might be interested in training on this topic
I would participate in an in home training on this topic
I would attend a training in home or in the office on this topic
I would pay to attend an in depth office training on this topic