Our Family Feedback Form

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Family Feedback Form

In order to serve you better, we know that it is important to accept any criticisms along with praise to excel in our business. We encourage you to provide us with your genuine comments on how well we served you in your time of need.

Personal Information

Name:
Address:
City:	Zip Code:
Phone:

Funeral Provider related feedback

Name of the Funeral Director who assisted you:

1. Why did you choose our practice? (Choose all that apply)

Service Prearranged

Religious Affiliation

Recommended by Clergy

Recommended by Friend

Previously Served Family

Reputation

Convenience of Arranging at Home

Use of Outside Facilities for Service

Prices

Other:

2. How did you hear about our practice?

	Newspaper	Yellow Pages
	Recommended by Clergy	Getting to Know You
	Staff Employee	Reputation
	Other (please specify):

3.During the arrangement conference, did you find the information provided helpful in making your selections? (please select only one)

Yes

No

Not Sure

4. Was our staff courteous?

Yes

No

Not Sure

5. Would you please rate the following, if they apply. (choose only one response for each item)

	Satisfied	Neutral	Dissatisfied
Initial Contact With Our Practice
Arrangement Conference
Funeral and Related Goods Selection
Arrangement Coordination With Third Party Providers
Viewing Experience if Selection Was a Traditional Funeral
Visitation and Service Atmosphere as Coordinated by Director
Sense of Personalization by Funeral Director
Staff Attitude

6. Please respond to the following statement,"The prices charged by our funeral provider were reasonable." (Choose the one that applies)

I Agree

I Disagree

Not Sure

7. Based on your experience, would you recommend our practice to others? (If the answer is no, please explain below in the provided comments box)

Yes

No

Not Sure

Additional Comments or Suggestions