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Final Client Satisfaction Survey

Please use this final client satisfaction survey and feedback form to give feedback about the counselling services you received at Cobb Counselling Inc.. 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 Inc. 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.

Final Client Satisfaction Survey

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).

Think of the problems or issues you wanted to resolve when you first came to counselling. Select a number below that best reflects how far you feel you have come in resolving those concerns.

*
Think of the problems or issues you wanted to resolve when you first came to counselling. Select a number below 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

For items #1-12, 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 felt comfortable with the direction we took in our sessions.*
6. I felt comfortable with the direction we took in our sessions.*

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

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

9. Counselling helped me to improve the quality of my life .

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

Counselling helped us to improve the quality of our lives together.*

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

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

12. I would confidently recommend the therapist to others.*
12. I would confidently recommend the therapist to others.*

13. Please use this space to provide additional comments on any of your ratings above, particularly any ratings that may be low. For each comment, please indicate the item number to which it corresponds.

Item #:

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 disappointed you about counselling or that would have made the process more helpful or useful to you?

16. Please check one statement(s) that best matches your reason for ending counselling.*
16. Please check one statement(s) that best matches your reason for ending counselling.*

	Resolved the problem(s) to my/our satisfaction
	Felt much better and didn’t see a need to keep coming
	I was not comfortable with the goals or methods used in counselling
	(If couples counselling) We had incompatible goals for counselling
	We could not afford to keep coming financially and/or our insurance coverage ended
	Other commitments or pressures came up that made it difficult to focus on counselling
	Did not feel counselling was really helping me (or us)
	Other

If Other, please specify:

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

Please enter the word that you see below.

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

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Final Client Satisfaction Survey

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