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Complimentary Consultation Feedback Form
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Today’s Date
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I/we felt heard and understood during the phone consultation.
Strongly Disagree
1
2
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4
5
Strongly Agree
Clear selection
The phone consultation answered my/our questions about therapy, style and fees.
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
This phone call was helpful in making my/our decision about moving forward with couples/individual therapy.
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
Please rate the length of the call
Not Long Enough
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5
Too Long
Clear selection
What was the most helpful or most important part of the phone call?
Your answer
What was the least helpful or least important part of the phone call?
Your answer
I/we scheduled my/our first session during this phone call.
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Yes
No
Required
If yes, please help us know what contributed to your decision.
Your answer
If no, please share your reasons so that we may continue to improve the Complimentary Phone Consultation service.
Your answer
If our practice was not the best fit for your needs, were other resources offered to you?
Yes
No
Clear selection
My First Name
Your answer
My complimentary phone consultation was provided by:
Kathleen Bromfield, Client Engagement Specialist
Laura Cross, LMFT - Owner/Founder of IRTC
LeThi Cussen
Other:
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