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What issues did you address in treatment? (Select as many as apply)
Anxiety/Fears/Phobia(s)
Relationship issues
Depression
Self-esteem
Personal growth
Sexual issues
Family conflict
Grief/loss
Life transition
Perfectionism/procrastination
Body image concerns
Job change or loss
Peer relationships
Alcohol/Substance Abuse
Career Counseling
Jealousy
Time-management
Weight loss
Other
How many sessions did you attend?
Select
1-5 sessions
6-10 sessions
11-15 sessions
16-20 sessions
21-25 sessions
26-30 sessions
Did you feel that your personal goal(s) for therapy were met?
My goals were partially met.
No‚ my goals were not met.
Other (please specify).
Please specify:
Please rate your satisfaction with our work together on the following dimensions.
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Professionalism
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Effectiveness of therapy
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
My listening skills
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Respect for you and your values
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Understanding of your goals
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Clarity and fairness of office policies
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Empathy
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Sensitivity to your needs
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Warmth
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Accessibility
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Compassion
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Communication between us
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Level of interaction and engagement with you
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Billing procedures
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Your belief that I genuinely cared for you
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Knowledge
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Humor
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
The degree to which I collaborated with you on treatment
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Helpfulness
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Your feelings about how therapy ended
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
My expertise
Very dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satsified
Very satisfied
Was my sensitivity to culture or diversity an important variable for you?
No‚ this was not important to me
I wanted someone sensitive to sexual issues.
I wanted someone sensitive to polyamory.
I wanted someone sensitive to BDSM/kink.
I wanted someone sensitive to gay/lesbian issues.
I wanted someone sensitive to disability issues.
I wanted someone sensitive to transgender issues.
I wanted someone sensitive to body size issues.
I wanted someone sensitive to sex work issues.
I wanted someone sensitive to Chicano‚ Latino‚ or Hispanic issues.
I wanted someone sensitive to African-American or Black issues.
I wanted someone sensitive to Asian-American or Pacific Islander issues.
I wanted someone sensitive to biracial/multicultural issues.
I wanted someone sensitive to Native-American or Indigenous issues.
I wanted someone sensitive to religious and spiritual issues.
If my sensitivity to culture or diversity was an important variable for you, please rate your satisfaction with this aspect of my work.
Very dissatisfied
Dissatisfied
Somewhat dissatisfied
Neutral
Somewhat satisfied
Satisfied
Very satisfied
How likely are you to recommend me to a friend or colleague?
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10
Is there anything else the therapist needs to know to make sure the therapeutic process is easier?
Done
Thank you for your feedback.
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