Feedback on Services Form

Office Use Only:
Date Received:
______________

Instructions: Please check and update all information for accuracy.
Once you fill out all fields, we recommend you to print of a hard copy..

Input Level of Agreement
Strongly Disagree <----------> Strongly Agree
 
1
2
3
4
5
NA
I received information that was useful to me.

Information that was provided was clear and understandable.
The consultant shared information in a helpful and respectful manner.
The service occurred at a time that was convenient for me.
I learned things I can do to help this child/student.

I feel I can implement the suggestions provided.

I feel it is important to maintain contact with the consultant to help meet the needs of child/student.
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