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 | | CLIENT QUESTIONNAIRE
This Client Questionnaire will be confidential. We will share the information you provide only with Roberta Roth’s personnel working on your specific program. The Client Questionnaire allows us to best meet your needs. Complete both sides of the form as thoroughly as possible. Please call us at 1-877-771-5437 with questions. Mail the completed form to us or fax it to (914)941-5753 as soon as possible.
ORGANIZATION INFORMATION
Organization: ___________________________________________________________
Address: ______________________________________________________________
City: _________________________________ State:_______Zip:________________
Phone: _______________________________Fax: _____________________________
Contact: _________________________________Title: _________________________
Alternate Contact: ________________________________Title: __________________
PROGRAM INFORMATION
Program Requested: --- On-Site Training ---Keynote ---Training Conference
Program Topic: _________________________________________________
Date: ___________________Time: from_______________to________________
Alternate Date: ____________________Time:from___________to___________
Expected Attendance: _______________________________________________
ORGANIZATION OVERVIEW
What is the principle business activity of your organization?_______________________
Why are you considering this program? _______________________________________
Please list the names of people who would be in a position to provide preprogram input to our staff regarding issues such as company style, needs, goals, etc. What is the best time of day to call them?
Name/Title: __________________________________Phone:______________________
Name/Title: __________________________________Phone: _____________________
Name/Title: __________________________________Phone: _____________________
Please provide as much of the following information as possible:
--- Mission Statement & Core Values --- Newsletters
--- Products or Service Brochures --- Organizational Charts
PARTICIPATION PROFILE
What are the job titles of the participants? ______________________________________
What are the participants ‘ attitudes and expectations about this program? ____________ ________________________________________________________________________
PROGRAM GOALS & OBJECTIVES
What specific areas should this program address? ______________________________
_____________________________________________________________________
How will determine the success of this program? ________________________________
_______________________________________________________________________
What areas should not be addressed? ________________________________________
______________________________________________________________________
What are the issues/concerns we need to be sensitive to? ________________________
What program has this group had in the past two years?___________________________
What did you like about the programs? ________________________________________
_______________________________________________________________________
What didn’t you like about the programs? ____________________________________
______________________________________________________________________
Suggestions to ensure that we successfully meet your needs: ________________
____________________________________________________________
Please mail or fax this completed
Client Questionnaire to:
Roberta Roth, CSW
P.O. Box 151
Scarsdale, NY 10583
PHONE 1-877-771-5437
FAX (914)941-5753
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