Client Experience and Satisfaction Survey

To make sure that you are receiving quality services, please complete this questionnaire. All responses are anonymous.


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Date *
MM
/
DD
/
YYYY
Therapist Name
Please indicate the type of services you are receiving from this therapist: *
Required
To what extent did the therapist: *
Not At All
Somewhat
Neutral
Mostly
Completely
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 need?
Understand your needs?
Help you define your needs?
Involve you in the treatment planning (such as treatment goals and frequency of appointment)?
Respond to your requests for services?
Are there some things you feel were especially good or helpful about your treatment?
In what ways do you feel we could improve? 
Are you going to continue treatment with this therapist?
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Would you recommend Lillybrook Counseling Services to friends and family? *
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