Session Impact Form:

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As part of my commitment to evidence-based, client-driven treatment, I invite You to complete this feedback form after each session, or as frequently as You feel called to. You have the option to remain anonymous when doing so, and You can complete or skip whatever questions You wish. Your honest impression of how things are going ensures that the interventions I'm offering are aligned with Your goals & needs.

Name

Date of Session

YYYY

How helpful was today's session?

Very Bad Session: It did not go well and not much was accomplished

Poor Session: It did not go well but some progress was made

Average Session - It was ok, I did get some things done

Good Session: It went well, I feel better

Great Session: It went very well, I feel much better and got a lot done

Other:

Clear selection

The interventions offered in this session matched my needs and goals.

Not at all

Very much

Clear selection

In this session, do You feel Your therapist understood You?

Not at all

Only a little

Somewhat

Quite a bit

Very Much

Other:

Clear selection

How have things been going for You the past 2 weeks?

Very Bad: Things are far worse than they were

Not So Good: There is no progress or things are somewhat worse

OK: There may be some improvement

Good: Things are much better

Great: Things are very much better

Other:

Clear selection

I feel a lot of blame, shame and guilt for the problems which brought me to therapy:

Not at all

Only a little

Somewhat

Quite a bit

Very Much

Other:

Clear selection

I understand something new and positive about myself, others (my family, coworkers, peers) and/or community:

Not at all

Only a little

Somewhat

Quite a bit

Very Much

Other:

Clear selection

I think we can find a solution to the problems which brought me to therapy:

Not at all

Only a little

Somewhat

Quite a bit

Very Much

Other:

Clear selection

How much progress did You feel You made in counseling with Asha?

Very Little Progress: sessions and interventions haven't helped alleviate my symptoms at all

Poor Progress: some sessions seem helpful but I'm still frequently struggling

Average Progress: sessions have been somewhat helpful and I'm doing ok

Good Progress: sessions have been regularly helpful and I'm doing somewhat better than when I came to therapy

Great Progress: sessions have been regularly very helpful and I'm meeting my goals for coming to therapy

Other:

Clear selection

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