Final Client Satisfaction Survey and Feedback Form

Please use this final client satisfaction survey and feedback form to give feedback about the counselling services you received at Cobb Counselling & Consulting. Your responses will provide important information about how services can be improved in the future. This form is meant to be completed after you have concluded counselling services and have no more scheduled visits.

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

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

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.

This final client satisfaction survey 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 submitting the survey.

Client Satisfaction Survey�Closing

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

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

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

	Male
	Female

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

For items #1-15, 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 felt supported and encouraged by the therapist.*

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

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

4. Things I learned in counselling helped me to make positive changes.*
4. Things I learned in counselling helped me to make positive changes.*

5. In our sessions we covered what was important to me.*
5. In our sessions we covered what was important to me.*

6. I/we had clear goals for what I (or we) wanted to accomplish in counselling.*
6. I/we had clear goals for what I (or we) wanted to accomplish in counselling.*

7. I/we made a lot of progress on reaching those goals.*
7. I/we made a lot of progress on reaching those goals.*

8. Counselling has helped me improve my life and strengthen my important relationships.

If you were in couples or family therapy please answer this statement instead:

Counselling has helped us strengthen our relationship with each other.*

9. Overall, therapy was very helpful.*
9. Overall, therapy was very helpful.*

10. I would come back to see the therapist again, if the need arose.*
10. I would come back to see the therapist again, if the need arose.*

11. I would recommend the therapist with confidence.*
11. I would recommend the therapist with confidence.*

12. At times, I felt uncomfortable about the direction we were taking in our sessions.*
12. At times, I felt uncomfortable about the direction we were 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.*

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 #:

14. What was most helpful to you or what did you like the most about the counselling services you received?

15. Was there anything that would have made the process more helpful or useful to you?

16. Please check the statement(s) that best match your reasons for ending counselling.

	Resolved the problem(s) to my/our satisfaction
	Felt much better and didn�t see a need to keep coming
	Got as far as we could get, and then couldn�t really go any farther right now (reached an impasse)
	Needed to take a break from therapy for a while
	Couldn�t afford to keep coming financially
	Other commitments or pressures came up and made it hard to focus on therapy
	Did not feel counselling was really helping me (or us)
	Other

If Other, please specify:

17. On a scale of 1-30 where
1 = the main issues that brought you to therapy 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 therapy 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 before submitting this form