Date of Visit:
Please indicate the type of service you are receiving:
TherapyEvaluation/ testingOther (administrative interactions)
Please answer the following questions about your experience:
To what extent did your provider:
Help you achieve the purpose for which you sought counseling?
Help you obtain skills that will help you handle future problems?
Show interest in your needs?
Understand your needs?
Help you define your needs?
Involve you in the treatment planning (such as treatment goals and frequency of appointments)?
Respond to your requests for services?
Treat you with dignity and respect?
Are you going to continue treatment with this therapist or would you return to your provider for services in the future if needed?
Do you have any specific concerns or complaints about your treatment?
Are there some things you feel were especially good or helpful about your treatment?
Please rate the efficiency and accuracy with which your scheduling and billing process occurred:
Please explain/additional comments: