Speech Videos Feedback Form

Customer Feedback

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name

E-mail Address*
E-mail Address*

City*
City*

State/Prov*
State/Prov*

Country*
Country*

Which video or videos did you purchase?

	Oral Motor Training
	Speech Activities - Level 1
	Speech Activities - Level 2
	Word Finding Exercises
	Language Activities - Level 1
	Language Activities - Level 2
	Language Activities - Level 3

How would you rate the quality
of the video you purchased?

	Excellent
	Very Good
	Good
	Fair
	Poor

How long have you
been using the video(s)?

	1-3 months
	4-6 months
	7-9 months
	10-12 months
	Over a year

How frequently do you practice
the exercises on your video?

	More than once a day
	Once every day
	5-6 times per week
	3-4 times per week
	1-2 times per week
	Not at all

Do you feel that the video has provided
some level of improvement?

	Good improvement
	Moderate improvement
	Some improvement
	Slight improvement
	No improvement

If used on a daily basis, do you think
our videos can be effective?

	Very Effective
	Reasonably Effective
	Somewhat Effective
	Not Effective

How would you rate the price of our products?

	Excellent Value
	Very Good Value
	Good Value
	Fair Value
	Acceptable Value
	Poor Value

Would you recommend our products to someone else?

	Yes
	Possibly
	No

How could we improve our videos?

Would you like to leave a testimonial? Please use the space below to tell us about your experience practicing speech therapy on a daily basis. All information is kept strictly confidential. We will email you to ask permission if we would like to use your comments on our website.

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