Patient Feedback
This form allows you an opportunity to provide feedback to your counselor after your sessions have finished. This will help your counselor's professional development as well as helping improve the service offered to others. You DO NOT need to identify yourself. Please check the box in which most closely corresponds to how you feel about each statement.
About the Working Relationship With Your Counselor
Strongly Agree
Somewhat Agree
Neutral
Somewhat Disagree
Strongly Disagree
My counselor listened to me effectively.
My counselor understood the things from my point of view.
My counselor focused on what was important to me.
My counselor accepted what I said without judging me.
My counselor showed warmth towards me.
My counselor fostered a safe and trusting environment.
My counselor began and finished our sessions on time.
My counselor challenged me when/if that was appropriate.
About the Results of Working With Your Counselor.
Strongly Agree
Somewhat Agree
Neutral
Somewhat Disagree
Strongly Disagree
The sessions with my counselor helped me with whatever originally led me to seek counseling.
Any changes which might have occurred in me as a result of my counseling have been positive and welcome.
Overall Satisfaction
Very Satisfied
Somewhat Satisfied
Neutral
Somewhat Dissatisfied
Strongly Dissatisfied
My overall level of satisfaction with the service provided by my counselor is:
Based on my experience, I would recommend my counselor to others.
Yes
No
Other Comments:
Please use this space for any other comments you would like to bring to your counselor's attention. (If there are any matters in which you specifically would not have wanted to discuss with your counselor in person, your counselor would be especially glad to know these.) If you include your name in this section, it will be treated as CONFIDENTIAL.
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