Feedback Form
Name (Optional)
First Name
Last Name
Clinician's Name
First Name
Last Name
My counseling experience was:
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Unhelpful
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2
3
4
5
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7
8
9
Transformative
10
1 is Unhelpful, 10 is Transformative
What are some examples of how your counseling experience was the rating above?
The therapist's approach was a good fit for me
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Strongly disagree
1
2
3
4
5
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7
8
9
Strongly agree
10
1 is Strongly disagree, 10 is Strongly agree
What are some examples of how the therapist's approach was the rating above?
The level of professionalism exhibited by my therapist(s)
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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 professionalism exhibited by the administrative staff:
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Poor
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2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
The timeliness of response from my therapist(s)
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Poor
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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 therapist(s)
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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 therapist(s)
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Poor
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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
I will recommend CCF to others
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Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Any challenges in making an appointment?
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
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