Services

About

Resources

Forms

Payments

Other

[?] Subscribe To This Site

Client Satisfaction Survey — Periodic (Every 3-4 Sessions)

Please use this client satisfaction survey form to provide your opinions and feedback about the counselling services you are receiving at Cobb Counselling Inc. and the progress you feel you are making. Your responses will help improve the quality of services you are receiving.

This client satisfaction survey is meant to be completed every three to four sessions. As with all client information, your responses will be kept strictly confidential. You do not need to provide your name or any identifying information other than your case ID number (you'll find it on your invoice) which allows me to identify you. When you hit the submit button your information will be stored on a secure server to which only I have access.

You are also free to complete this survey by hardcopy if you prefer. If you choose the hardcopy option, you can fax your completed survey to me at (403) 255-8570 (confidential fax) or you can bring it with you to your next session.

Please refer to the privacy policy for Cobb Counselling Inc. if you have any questions about privacy and your personal information.

This form should take about 5-10 minutes to complete. You do not have to complete all of it before you submit it, but you do need to finish what you intend to submit in one sitting as you cannot save a partially completed form and come back to it later to continue working on it. If you close the browser window before hitting the submit button your information will be lost. If you would like to retain a copy, please print this page on your browser before you submit the survey.

Client Satisfaction Survey—Periodic

Please note that all fields followed by an asterisk must be filled in.

Case Number
(As it appears on a recent invoice. This helps me to identify you.)*

Gender
(If you are coming with your spouse or partner, this helps me to identify you further, but it is not required.)

	Male
	Female

Age
(if you are coming with your family, this helps me to identify you further, but it is not required.)

For items #1-10, please use the drop down list under each item to indicate how much you agree or disagree with each statement. On this scale, 0=strongly disagree and 10=strongly agree.
1. I feel supported and encouraged by the therapist.*

2. The therapist understands my concerns and feelings.*
2. The therapist understands my concerns and feelings.*

3. The therapist's approach is a good fit for me.*
3. The therapist's approach is a good fit for me.*

4. Things I am learning in counselling are helping me to make positive changes.*
4. Things I am learning in counselling are helping me to make positive changes.*

5. In our sessions we are covering what is important to me.*
5. In our sessions we are covering what is important to me.*

6. I am comfortable with the direction we are taking in our sessions.*
6. I am comfortable with the direction we are taking in our sessions.*

7. I (or we) have clear goals for what I (or we) want to accomplish in counselling.*
7. I (or we) have clear goals for what I (or we) want to accomplish in counselling.*

8. I am (or We are) making a lot of progress on reaching these goals.*
8. I am (or We are) making a lot of progress on reaching these goals.*

9. Counselling is helping me improve the quality of my life.

(For couples or family therapy, please answer this statement instead):

Counselling is helping us improve the quality of our lives together.*

10. Overall, counselling has been very helpful so far.*
10. Overall, counselling has been very helpful so far.*

11. Please use the spaces below to provide additional comments on any of your ratings above, particularly any ratings that may be low. For each comment, please mark the item number to which it corresponds.

Item #:

12. So far, what has been most helpful or what have you liked the most about the counselling services you are receiving?

13. Is there anything that would make the process more helpful or useful to you?

(i.e. Are there topics you wish we were discussing, things you wish I would do more of or less of, approaches that aren't working, etc..)

14. Think of the concerns you had when you first came to counselling. On the scale below, please indicate the number that best reflects how far you feel you have come in resolving those concerns.

*
14. Think of the concerns you had when you first came to counselling. On the scale below, please indicate the number that best reflects how far you feel you have come in resolving those concerns.

*

	0.0 No Change or Worse
	0.5
	1.0 Some Improvement
	1.5
	2.0 Moderate Improvement
	2.5
	3.0 Much Improvement
	3.5
	4.0 Mostly Resolved
	4.5
	5.0 Resolved

15. Please indicate the number that best reflects how far you feel you expected to have come by now.

*
15. Please indicate the number that best reflects how far you feel you expected to have come by now.

*

	0.0 No Change or Worse
	0.5
	1.0 Some Improvement
	1.5
	2.0 Moderate Improvement
	2.5
	3.0 Much Improvement
	3.5
	4.0 Mostly Resolved
	4.5
	5.0 Resolved

16. Please add any other comments you wish to make here before submitting this form.

Please enter the word that you see below.

Nathan Cobb, Ph.D.
Registered Marriage
& Family Therapist
Registered Psychologist

QUICK LINKS

Intake Forms
Hours & Location
Specialties
Fees

For Email Newsletters you can trust

A MARRIAGE CHECKUP

Brief & affordable
Click here for more information

TOPICS

Addiction

Affair Recovery

Anger Control

Resolving Conflict

Depression

Marriage Counselling

Pre-Marital Counselling

Stress Management

ARTICLES

How Can I Be A Better Listener?

Can Our Marriage Be Saved?

Communication Tips

How to Stop Arguing and Shift to More Productive Dialogue

How to Talk Productively About Your Differences

Why Goodwill is Essential to Good Communication

Fair Fighting Rules for Couples

More Articles ...

Client Satisfaction Survey — Periodic (Every 3-4 Sessions)

QUICK LINKS

NEWSLETTER

A MARRIAGE CHECKUP

TOPICS

ARTICLES