Counselling Evaluation Form

Counselling Evaluation Form
Date*

DayMonthYear
First Name*
Given name
Last Name*
Surname
Gender :*
Name of Counsellor :*
IndividualCoupleFamily
Please indicate your responses to the following questions :

1. I was able to book the appointment without any difficulty*

	1	2	3	4	5

1 is Disappointing, 5 is Excellent

2. The staff who attended to me administratively was helpful*

	1	2	3	4	5

1 is Disappointing, 5 is Excellent

3. The counsellor created a safe environment for me to share my struggles*

	1	2	3	4	5

1 is Disappointing, 5 is Excellent

4. I felt understood, supported, and cared for.*

	1	2	3	4	5

1 is Disappointing, 5 is Excellent

5. The counsellor was able to assess and explain what was troubling me.*

	1	2	3	4	5

1 is Disappointing, 5 is Excellent

6. The counsellor guided me to establish clear goals to resolve my issues(s).*

	1	2	3	4	5

1 is Disappointing, 5 is Excellent

I experienced relief, healing during the sessions.I gained insights into my issues(s).I was able to apply some practical solutions that helped me to cope better.I feel confident to navigate the challenges that I sought help for.I feel empowered to pursue greater well-being for myself.

8. How satisfied are you with the overall counselling experience?*

	1	2	3	4	5

1 is Disappointing, 5 is Excellent

YesNo
YesNo
YesNo
12. Please share how the sessions have benefitted you :*
YesNo
Marriage PreparationMarriage EnrichmentParenting ProgrammesMental Health Webinars
Yes, I would like to be on the Focus on the Family mailing list.No, I do not wish to be on the mailing list
Thank you for your feedback! We wish you the best as you continue to author the

future chapters of your life.
Should be Empty: