Client Satisfaction Survey and Feedback Form

Please use this client satisfaction survey form to provide your opinions and feedback about the counselling services you are receiving at Cobb Counselling & Consulting 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 & Consulting 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 #1-13, 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. Dr. Cobb shows respect for me as a person.*

2. Dr. Cobb understands my concerns and feelings.*
2. Dr. Cobb understands my concerns and feelings.*

3. Dr. Cobb's approach is a good fit for me.*
3. Dr. Cobb'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. Dr. Cobb has offered helpful suggestions and guidance so far.*
6. Dr. Cobb has offered helpful suggestions and guidance so far.*

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. I am gaining new perspectives that lead to solutions.*
9. I am gaining new perspectives that lead to solutions.*

10. Counselling is helping me strengthen my important relationships.

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

Counselling is helping us strengthen our relationship with each other.*

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

12. At times I feel uncomfortable about the direction we are taking in our sessions.*
12. At times I feel uncomfortable about the direction we are taking in our sessions.*

13. If I was dissatisfied with some part of the counselling services I was receiving it would be hard for me to bring it up with the therapist.*
13. If I was dissatisfied with some part of the counselling services I was receiving it would be hard for me to bring it up with the therapist.*

14. 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 #:

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

16. 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..)*

16. 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..)*

17. On a scale of 1-30 where
1=the main issues that brought you to counselling are worse than ever and cause you a great deal of distress (i.e. low mood, anger management, distressed marriage, family conflict, etc.)
and
30=the main issues are fully resolved and you feel you are doing very well
please use the drop down list below to indicate how far you feel you have come toward resolving those main issues.*
17. On a scale of 1-30 where
1=the main issues that brought you to counselling are worse than ever and cause you a great deal of distress (i.e. low mood, anger management, distressed marriage, family conflict, etc.)
and
30=the main issues are fully resolved and you feel you are doing very well
please use the drop down list below to indicate how far you feel you have come toward resolving those main issues.*

In answering the previous question, I was thinking of*
In answering the previous question, I was thinking of*

	How I am doing as an individual
	How we are doing as a couple
	How we are doing as a family

Please indicate where you feel you were on this scale when you started counselling?*
Please indicate where you feel you were on this scale when you started counselling?*

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

Client Satisfaction Survey � Periodic