Client Satisfaction Survey Form

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Client Satisfaction Survey

We appreciate your feedback!

1
Your Name (Optional)(Required, if you would like us to follow up with you.)
First Name
Last Name
2
The Name of Your Therapist* This field is required.
3
Overall SatisfactionPlease complete your evaluation of your therapy experience with us.
Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Overall satisfaction
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I felt heard, understood, and respected.
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We worked on and talked about what I wanted to work on and talk about.
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The therapist’s approach is a good fit for me.
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Overall, the therapist was a good fit for me.
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Were your counseling goals met?
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Overall satisfaction
I felt heard, understood, and respected.
We worked on and talked about what I wanted to work on and talk about.
The therapist’s approach is a good fit for me.
Overall, the therapist was a good fit for me.
Were your counseling goals met?
Very satisfied
Row 0, Column 0
Satisfied
Row 0, Column 1
Neutral
Row 0, Column 2
Unsatisfied
Row 0, Column 3
Very unsatisfied
Row 0, Column 4
Very satisfied
Row 1, Column 0
Satisfied
Row 1, Column 1
Neutral
Row 1, Column 2
Unsatisfied
Row 1, Column 3
Very unsatisfied
Row 1, Column 4
Very satisfied
Row 2, Column 0
Satisfied
Row 2, Column 1
Neutral
Row 2, Column 2
Unsatisfied
Row 2, Column 3
Very unsatisfied
Row 2, Column 4
Very satisfied
Row 3, Column 0
Satisfied
Row 3, Column 1
Neutral
Row 3, Column 2
Unsatisfied
Row 3, Column 3
Very unsatisfied
Row 3, Column 4
Very satisfied
Row 4, Column 0
Satisfied
Row 4, Column 1
Neutral
Row 4, Column 2
Unsatisfied
Row 4, Column 3
Very unsatisfied
Row 4, Column 4
Very satisfied
Row 5, Column 0
Satisfied
Row 5, Column 1
Neutral
Row 5, Column 2
Unsatisfied
Row 5, Column 3
Very unsatisfied
Row 5, Column 4
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4
If you needed counseling in the future, would you return to Rum River Counseling?
YESNO
5
Would you recommend Rum River Counseling to someone who wanted counseling?
YESNO
6
What did you find MOST helpful about your therapist or your therapy experience at Rum River Counseling?
7
What did you find LEAST helpful about your therapist or your therapy experience at Rum River Counseling?
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Large
Normal
Small
Ok
Ok
8
Additional comments or ideas on how to improve our services:
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Large
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Small
Ok
Ok
9
Would you like us to follow up with you regarding any concerns?
YESNO
10
If yes, what is the best way to reach you?
Phone Call
Email
Either Phone Call or Email
11
Email
example@example.com
12
Phone Number
Area Code
Phone Number
13
Please verify that you are human* This field is required.
Should be Empty:

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