Feedback Form

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Feedback Form

We appreciate you taking the time to complete this survey. As a reminder, your feedback will be anonymous unless you choose to identify yourself. This information will provide feedback to your therapist's clinical supervisor to ensure they are providing the best treatment for you.

In regards to the feedback you're providing, please select one of the following boxes *

I'd like you to address this with my therapist anonymously

I'd like you to address this with my therapist, explicitly using my name

Name (optional)

Type of Therapy *

Individual

Couple

Family

Please respond to the following statements on a scale of 1 (strongly disagree) to 5 (strongly agree)

I feel my therapist has a solid understanding of what has brought me to therapy. *

Strong disagree

Strongly agree

I feel my therapist is effectively addressing the issue that brought me to therapy. *

Strongly disagree

Strongly agree

I find my therapist to be warm. *

Strongly disagree

Strongly agree

I believe my therapist is knowledgeable. *

Strongly disagree

Strongly agree

I trust my therapist. *

Strongly disagree

Strongly agree

I feel my therapist is uncovering and shedding light on the dynamics in my relationships with others (in and out of therapy). *

Strongly disagree

Strongly agree

My therapist is providing resources (i.e. homework, book recommendations, tools to use in and out of session) in the way I'd hope. *

Strongly disagree

Strongly agree

I feel my therapist is reliable (i.e. on time, consistent, few or no scheduling changes).

Strongly disagree

Strongly agree

Clear selection

I feel a sense of hope and confidence in the therapy process. *

Strongly disagree

Strongly agree

I would recommend my therapist to a friend or family member in need of therapy. *

Yes

Would you like to provide additional comments or feedback about your experience so far?

What would make your experience with your therapist even better going forward?

Submit

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