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The service you received:

Speech/Language Evaluation
Speech/Language Therapy
Hearing Evaluation
Hearing Aid Services
Specialized Audiological Evaluation

About You:

How did you learn about the Hearing, Speech, and Language Clinic?

Social Media
From friends and/or family
Flyers
Other

Are you affiliated with the University?

Yes
No

Registration:

Registration:
	Very Poor	Poor	Fair	Good	Very Good
Helpfulness of the person at the front desk	Very Poor	Poor	Fair	Good	Very Good
Ease of registering	Very Poor	Poor	Fair	Good	Very Good
Waiting time	Very Poor	Poor	Fair	Good	Very Good
Billing and insurance questions answered	Very Poor	Poor	Fair	Good	Very Good

Facility:

Facility:
	Very Poor	Poor	Fair	Good	Very Good
Comfort of waiting area	Very Poor	Poor	Fair	Good	Very Good
Clarity of directions to our clinic	Very Poor	Poor	Fair	Good	Very Good
Ease of parking	Very Poor	Poor	Fair	Good	Very Good
Cleanliness of the facility	Very Poor	Poor	Fair	Good	Very Good

Your Visit:

Your Visit:
	Very Poor	Poor	Fair	Good	Very Good
Friendliness of the staff/students	Very Poor	Poor	Fair	Good	Very Good
Comfort with graduate students administering the service	Very Poor	Poor	Fair	Good	Very Good
Visibility/confidence in supervisors	Very Poor	Poor	Fair	Good	Very Good
Attentiveness to your questions	Very Poor	Poor	Fair	Good	Very Good
Explanations of the evaluations	Very Poor	Poor	Fair	Good	Very Good
Explanations of the treatment sessions	Very Poor	Poor	Fair	Good	Very Good

Personal Issues:

Personal Issues:
	Very Poor	Poor	Fair	Good	Very Good
Staff concern for your privacy	Very Poor	Poor	Fair	Good	Very Good
Staff sensitivity to your needs	Very Poor	Poor	Fair	Good	Very Good
Response to your concerns/complaints	Very Poor	Poor	Fair	Good	Very Good

Overall Assessment

Overall Assessment
	Very Poor	Poor	Fair	Good	Very Good
Likelihood of returning for future services	Very Poor	Poor	Fair	Good	Very Good
Likelihood of recommending the Clinic to others	Very Poor	Poor	Fair	Good	Very Good
Overall rating of the services you received	Very Poor	Poor	Fair	Good	Very Good

Any other comments or concerns?

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