Individual Feedback Form
Your therapist:
Please rate your response to the following statements:
My therapist heard and understood me
*
Strongly Agree
Agree
Unsure
Disagree
Strongly Disagree
Please select a response.
My therapist did not "judge" me
*
Strongly Agree
Agree
Unsure
Disagree
Strongly Disagree
Please select a response.
I am better off for coming to see this therapist
*
Strongly Agree
Agree
Unsure
Disagree
Strongly Disagree
Please select a response.
I am hopeful that I can achieve our goals for therapy
*
Strongly Agree
Agree
Unsure
Disagree
Strongly Disagree
Please select a response.
I plan to continue therapy with this therapist
*
Strongly Agree
Agree
Unsure
Disagree
Strongly Disagree
Please select a response.
I would recommend this therapist to others
*
Strongly Agree
Agree
Unsure
Disagree
Strongly Disagree
Please select a response.
Please let us know what is NOT going well in therapy that you would like to see change (OPTIONAL):
Please let us know what is going well in therapy that you would like to see continue (OPTIONAL):
Please answer all required questions before submitting.
Submit