Social Skill Builder Customer Survey
www.socialskillbuilder.com
1
. Name
Name
Name:
Company:
Address:
Address 2:
City/Town:
State:
-- select state --
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP:
Country:
2
. Email Address
Email Address
3
. Profession
Profession
Parent/Grandparent
Speech Therapist
Administrator
Educator
Psychologist/Counselor
Therapist
Other
4
. How did you hear about Social Skill Builder?
How did you hear about Social Skill Builder?
Advertisement
Conference
Referral from parent or professional
Article
Web Search
Mailer
Email
Other
Other (please specify)
5
. If you heard about us from a ad/conference, please list publication or conference
If you heard about us from a ad/conference, please list publication or conference
6
. What Social Skill Builder Programs are you most interested in or own?
What Social Skill Builder Programs are you most interested in or own?
Preschool Playtime
My School Day
My Community
School Rules!
The Birthday Party
7
. What age group are you most interested in?
What age group are you most interested in?
0-5 years
5-9 years
10-13 years
13-21 years
adult
8
. Did you have any problems installing or running the programs? If so what are they?
Did you have any problems installing or running the programs? If so what are they?
9
. Please add any comments you have about the usage or outcomes of using the programs
Please add any comments you have about the usage or outcomes of using the programs
10
. Who make decisions on software/materials purchases at your school or workplace? Please provide contact information
Who make decisions on software/materials purchases at your school or workplace? Please provide contact information
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