Final Symptom Follow-up and Client Satisfaction Survey

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

If you prefer, you can complete this survey by hardcopy (click here) and return the completed survey to me by email, mail or by confidential fax at (403) 255-8570.

As with all client information, your responses will be kept strictly confidential. We will need some type of identifier that will help us match your responses with your case that we have on file. This could be your Case ID number (which you'll find on a recent invoice), or the date and time of your last session if you know it, or your last name and first initial, an email address, or some other identifier that we can use to match your responses. Please refer to the privacy policy for Cobb & Associates Inc. if you have any questions about privacy and your personal information.

It should take about 5 minutes to complete or 48 clicks of your mouse (more if you wish to add comments). You will 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 would like to retain a copy, please print this page on your browser before submitting the survey.

Please note that all fields followed by an asterisk must be filled in.
This could be a Case ID number which you'll find on a recent invoice, or the date and time of your last session if you know it, or you could use the first three letters of your last name and first initial, or some other identifier that you have pre-arranged with your therapist.*
(If you came with your spouse or partner, this helps us to identify you further.)*
Male
Female
Cobb
Millington
Gibson
Christens
0.0 No Improvement
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
0.0 No Improvement
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


6. Not talking to each other.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


7. Having bad arguments.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


8. Lack of trust between us.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


9. Feeling lonely in the relationship.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


10. Lack of affection and caring between us.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


11. Feeling unhappy about our relationship overall.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


12. Feeling sad, down or depressed.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


13. Avoiding certain people or places.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


14. Loss of interest in activities I normally enjoy.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


15. Low energy / feeling tired.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


16. Sleep problems (not falling asleep, not staying asleep, or early waking).*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


17. Eating too much or not eating enough.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


18. Not able to think clearly.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


19. Feeling no joy or pleasure in life.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


20. Attacks of anxiety.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


21. Worrying about things.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


22. Angry outbursts.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


23. Low self-esteem or low self-confidence.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


24. Feeling guilty.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


25. Feeling too stressed.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


26. Thoughts of suicide.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


27. Drinking too much or abusing drugs (i.e. street drugs or prescribed medications).*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


28. Acting out other compulsive behaviors (i.e. gambling, sex, porn, shopping).*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


29. Not getting my work done.*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme


30. Feeling unhappy with my workplace (including your home if you work at home or your daily household work if you do not have paid work outside the home).*
0 None or N/A
1 A Little
2 Moderate
3 A Lot
4 Extreme

31. I felt supported and understood by the therapist.*

1 Strongly Disagree
2 Disagree
3 Partly Agree, Partly Disagree
4 Agree
5 Strongly Agree
Comment (Optional)


32. The therapist's approach or style was a good fit for me.*
1 Strongly Disagree
2 Disagree
3 Partly Agree, Partly Disagree
4 Agree
5 Strongly Agree
Comment (Optional)


33. Things I learned in counselling helped me to make positive changes.*
1 Strongly Disagree
2 Disagree
3 Partly Agree, Partly Disagree
4 Agree
5 Strongly Agree
Comment (Optional)


34. I gained new insights that changed my views on my situation for the better.*
1 Strongly Disagree
2 Disagree
3 Partly Agree, Partly Disagree
4 Agree
5 Strongly Agree
Comment (Optional)


35. I tried out new patterns of behavior in our sessions and between sessions that did help me.*
1 Strongly Disagree
2 Disagree
3 Partly Agree, Partly Disagree
4 Agree
5 Strongly Agree
Comment (Optional)


36. In our sessions we did cover what was important to me to talk about.*
1 Strongly Disagree
2 Disagree
3 Partly Agree, Partly Disagree
4 Agree
5 Strongly Agree
Comment (Optional)


37. I (or we) had clear goals for what I (or we) wanted to accomplish in counselling.*
1 Strongly Disagree
2 Disagree
3 Partly Agree, Partly Disagree
4 Agree
5 Strongly Agree
Comment (Optional)


38. I (or We ) made progress toward reaching those goals.*
1 Strongly Disagree
2 Disagree
3 Partly Agree, Partly Disagree
4 Agree
5 Strongly Agree
Comment (Optional)


39. Counselling helped me improve the quality of my life.

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

Counselling helped us improve the quality of our lives together.*
1 Strongly Disagree
2 Disagree
3 Partly Agree, Partly Disagree
4 Agree
5 Strongly Agree
Comment (Optional)


40. Overall, counselling was very helpful to me (or us).*
1 Strongly Disagree
2 Disagree
3 Partly Agree, Partly Disagree
4 Agree
5 Strongly Agree
Comment (Optional)


41. I would come back to see the therapist again if the need arose.*
Yes, For Sure
Not Sure
No
Comment (Optional)


42. I would recommend the services of Cobb & Associates Inc. without reservation.*
Yes, For Sure
Not Sure
No
Comment (Optional)


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


44. Was there anything that disappointed you about counselling or that would have made the process more helpful or useful to you?

(i.e. Were there topics you wished you and your therapist had discussed, things you wished the therapist had done more of or less of, approaches that were not working, etc..)



45. Please check one of the statements below that best matches your primary reason for ending counselling.

Resolved the problem(s) to my/our satisfaction
Felt much better and didn’t see a need to keep coming
Was referred by the therapist to a different resource who was a better fit for my/our concerns
I did not feel like there was a good fit between myself and the counsellor or the methods used in counselling
Did not feel counselling was really helping me (or us)
I (or 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
I was not ready for or committed to the process of seeking counselling
My partner or I decided to terminate the relationship (if couples counselling)
I would have kept coming but my partner did not want to come anymore (if couples counselling)
Other


Please feel free to elaborate here, if desired:


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