Feedback Form
Name (Optional)
First Name
Last Name
Counselor's Name
*
First Name
Last Name
My counseling experience was:
*
Unhelpful
1
2
3
4
5
6
7
8
9
Transformative
10
1 is Unhelpful, 10 is Transformative
What are some examples of why your counseling experience received the rating above?
The counselor's approach was a good fit for me:
*
Strongly disagree
1
2
3
4
5
6
7
8
9
Strongly agree
10
1 is Strongly disagree, 10 is Strongly agree
What are some examples reflecting how your needs or expectations were met (or not) by your counselor's approach?
The level of professionalism shown by my counselor:
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
The level of professionalism shown by the administrative staff:
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Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
The timeliness of response from my counselor:
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
The timeliness of response from the administrative staff:
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Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
The level of care provided by my counselor:
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Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
The level of trust I have in my counselor:
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
My overall experience at CCF:
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Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Would I recommend CCF to others:
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No
1
2
3
4
5
6
7
8
9
Yes
10
1 is No, 10 is Yes
Were there any challenges in making an appointment?
Were there any challenges in making a donation?
How can Cornerstone serve you better?
Additional comments
I give my permission to Cornerstone Counseling Foundation to publish my comments in promotional materials.Cornerstone Counseling Foundation's Commitment: Any materials used will remain anonymous. No names will be published
Yes
No
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