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Easter Seals Family Satisfaction Survey
1.

Please enter today's date:
 

50 characters left.
2.

Please tell us about you and your family.

First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

3.

I receive the following services from Easter Seals: (Please feel free to add the name of your service provider(s)
Occupational Therapy
Physical Therapy
Speech Therapy
Feeding Therapy
Central Illinois Orofacial Anomalies Team Clinic
Developmental Therapy
Aquatic Therapy
Counseling
Autism Diagnostic Clinic
Applied Behavior Analysis
The P.L.A.Y. Project
Assistive Technology Clinic
Orthotics Clinic
Rehabilitation Coordination
Other
  • Comment:

  • 500 characters left.
4.

Staff are friendly, professional, helpful, knowledgeable and prompt.
 Very Dissatisfied Somewhat Dissatisfied Satisfied Very Satisfied Extremely Satisfied N/A 
Therapists
Coordinators
Receptionists
Client Financial Services
  • Comment:

  • 500 characters left.
5.

Staff listen to our concerns and answer our questions.
 Very Dissatisfied Somewhat Dissatisfied Satisfied Very Satisfied Extremely Satisfied N/A 
Therapists
Coordinators
Receptionists
Client Financial Services
6.

Have the team/therapist recommendations been clearly communicated with you?
 Very Dissatisfied Somewhat Dissatisfied Satisfied Very Satisfied Extremely Satisfied 
Therapists
Clinic Team
  • Comment:

  • 500 characters left.
7.

Realistic goals were discussed and set.
 Very Dissatisfied Somewhat Dissatisfied Satisfied Very Satisfied Extremely Satisfied 
Therapists
Coordinators
  • Comment:

  • 500 characters left.
8.

The frequency and length of sessions meet our expectations.
 Very Dissatisfied Somewhat Dissatisfied Satisfied Very Satisfied Extremely Satisfied N/A 
Therapy
Specialty Clinic
  • Comment:

  • 500 characters left.
9.

We accessed services in a timely manner.
 Very Dissatisfied Somewhat Dissatisfied Satisfied Very Satisfied Extremely Satisfied 
Thearpy
Specialty Clinic
  • Comment:

  • 500 characters left.
10.

My child is making progress.
 Very Dissatisfied Somewhat Dissatisfied Satisfied Very Satisfied Extremely Satisfied N/A 
Therapy
Specialty Clinic
11.

Staff give us a good understanding of our child's abilities and potential.
 Very Dissatisfied Somewhat Dissatisfied Satisfied Very Satisfied Extremely Satisfied N/A 
Therapist(s)
Physician(s)
  • Comment:

  • 500 characters left.
12.

My child likes coming to Easter Seals.
 Very Dissatisfied Somewhat Dissatisfied Satisfied Very Satisfied Extremely Satisfied N/A 
Peoria Facility
Bloomington Facility
  • Comment:

  • 500 characters left.
13.

The environment and facilities are safe, attractive and accessible.
 Very Dissatisfied Somewhat Dissatisfied Satisfied Very Satisfied Extremely Satisfied N/A 
Peoria Facility
Bloomington Facility
  • Comment:

  • 500 characters left.
14.

As a result of services, my family and I experienced (choose all that apply):
Reduced stress
Improved parent/child interaction
A better understanding of my child
Improved quality of life
  • Comment:

  • 500 characters left.
15.

Based on my experience, I would feel comfortable referring other families to the program.
Not at all Yes Definitely         
        
  • Comment:

  • 500 characters left.

Please help us improve our services to your family and others by answering the following questions.
 
16.

Are there any other services you have an interest in that are not currently being provided?
 

350 characters left.
17.

Is your child currently receiving services other than those provided by Easter Seals?
Early Childhood Education Program at School
Private Pre-School
Therapy in the School
General School Services
Therapy with another Provider
Community Recreation Program
None
Other
  • Comment:

  • 500 characters left.
18.

Are there additional resources we can help you with?
Behavioral Therapy
Disability Specific Education
Therapeutic Resources
Equipment
Advocacy
Parent Support Group
Clicnet Centered Support Group
Other
  • Comment:

  • 500 characters left.
19.

Please add any additional comments regarding your experience with Easter Seals.
 

350 characters left.