What issues did you address in treatment? (Select as many as apply)

How many sessions did you attend?

Did you feel that your personal goal(s) for therapy were met?

Please specify:

Please rate your satisfaction with our work together on the following dimensions.

  Very dissatisfied Somewhat dissatisfied Neutral Somewhat satsified Very satisfied
Effectiveness of therapy
My listening skills
Respect for you and your values
Understanding of your goals
Clarity and fairness of office policies
Sensitivity to your needs
Communication between us
Level of interaction and engagement with you
Billing procedures
Your belief that I genuinely cared for you
The degree to which I collaborated with you on treatment
Your feelings about how therapy ended
My expertise

Was my sensitivity to culture or diversity an important variable for you?

If my sensitivity to culture or diversity was an important variable for you, please rate your satisfaction with this aspect of my work.

How likely are you to recommend me to a friend or colleague?

Is there anything else the therapist needs to know to make sure the therapeutic process is easier?

Thank you for your feedback.