Client Satisfaction Survey Form

Client Satisfaction Survey

Please take a moment to fill out this survey. Your responses are greatly appreciated!
Please select your clinician below:

Please rate the state of your overall health and emotional well-being:

Rows	Poor	Fair	Good	Very Good	Excellent	N/A
Three weeks PRIOR to beginning treatment here
Three weeks AFTER starting treatment here
At the end of your treatment here
Currently

How would you rate the state of the specific issue that brought you here:

Rows	Poor	Fair	Good	Very Good	Excellent	N/A
Three weeks PRIOR to beginning treatment here
Three weeks AFTER starting treatment here
At the end of your treatment here
Currently

When was your last or most recent session with us?

Please rate the following:

Rows	Poor	Fair	Good	Very Good	Excellent
Your ability to sustain the positive strides you made in treatment with us
The overall helpfulness of your therapist
The overall effectiveness of the therapy you have received with us
The overall level of communication with your therapist here
The overall helpfulness of our administrative team

Would you recommend our therapy service to others?

YesNoMaybe
Your feedback is very important to us. In the box below, please list any specific strengths or areas of improvement for your therapist and Simply Being Wellness Counseling.
If you would like us to follow up with you based on your responses, please feel free to leave your name below and we will reach out to you! (Optional)
Should be Empty: