Prospective Client Outcome Survey

Your Name*

First NameLast Name
Consult Name*

First NameLast Name
I received a client referral from Clarity’s matching process or elsewhere (colleague, PsychToday, etc)I never heard back from the client (and it’s been 2 weeks or more)The consult no showed or canceledThe consult took place, but the client decided not to move forwardI don't see my reason here
Don't see a reason above that applies to your situation?
You likely don't need to fill out this form.

For any doubts or questions, please contact lauren@claritytherapynyc.com.
Matching questionnaireAnother Clarity therapistOutside source, colleague, physician or psychiatristTherapist platform or directory (I.e. PsychToday)My own social mediaUnknownOther
YesNo
Which directory or platform?
Enter how the client came to know about you (I.e. PsychToday, TherapyDen, Manhattan Alternative, etc)
Clarity website or general email inquiryOther Clarity TherapistOnline searchOnline DirectoryFriend or family memberColleague or outside therapistPhysician or psychiatristSocial media
PhoneVideoConsult didn't occur
There was no communication between client and myself (i.e. Me or the client did not follow up)Consult never responded to emails or phone callConsult didn’t show for scheduled consultationClient canceled consultOther
No referral was provided to the consultTo someone within ClarityOutside of ClarityClient was encouraged to reach out to the client care team for rematching/additional referralsI need help with providing a referral to the consultOther
Fee/paying for therapy was a concernBilling/insurance issues/concernsSpecialty area or approach not offeredClient/therapist availability or schedule did not alignClient was unsure about timeline for starting therapyPersonality/rapport fitClient found another therapistClient needed a different or higher level of careOther
Please elaborate on the above concerns you identified:*
(I.e. the client was looking exclusively for EMDR which I do not offer at this time, so a referral was provided)
What’s the follow up plan?*
(i.e. Nirvana to check on benefits, therapist will share info via email and encourage client to schedule 1st session)
Should be Empty: