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Session Evaluation

This survey is meant to be completed after each session. 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 instead, you can fax your completed survey to me at (403) 255-8570 (confidential fax) or 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 survey should take about 2-5 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 want to keep a copy for your own records, please print this page on your browser before you submit the survey.

Session Evaluation

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, this helps me to identify you further, but it is not required)

	Male
	Female

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

Date of Session*
Date of Session*

I. HELPFULNESS OF THE SESSION
a. On a scale of 1-10 rate how helpful this session was for you.

(i.e. In terms of feeling heard and understood, creating a plan, fostering hope, understanding the issues better, being able to talk things out, etc..)*

I. HELPFULNESS OF THE SESSION
a. On a scale of 1-10 rate how helpful this session was for you.

(i.e. In terms of feeling heard and understood, creating a plan, fostering hope, understanding the issues better, being able to talk things out, etc..)*

	1 Not Helpful
	2
	3
	4
	5
	6
	7
	8
	9
	10 Very Helpful

b. Please explain your rating. That is, what specifically made the session helpful for you?

c. Is there anything that might have made the session more helpful than it was?

(i.e. Are there topics you wish we were discussing, things you wish I would start doing or stop doing, approaches that aren't working, etc..)

II. CHANGE MOMENTS

If you rated the helpfulness of the session high, you may find it beneficial to complete the next two questions.

a. Please describe any significant “change moments” that occurred for you during the session (if any).

Note: A change moment is a definite and positive shift in your emotions, perspective, behavior, or attitude that creates possibilities or leads to solutions. Examples include seeing a new perspective, learning something new about yourself, seeing your partner in a different way, letting go of hard feelings, or developing a skill that helps you to accomplish your goals.

b. What do you think contributed to the change moment(s) you just described?

For example, think about what you did/said, what your spouse or another family member did/said, or what the therapist did/said to invite the change. Think about what was happening just before the positive changes occurred.

III. CLEAR PLAN
"I have some clear ideas about what I need to focus on to resolve the issues that prompted me to seek counselling."*
III. CLEAR PLAN
"I have some clear ideas about what I need to focus on to resolve the issues that prompted me to seek counselling."*

	True
	False

What is your goal (or goals) between now and next session?

If you can, please write down two specific action steps you will take—something specific and positive you will do or think about in the coming week—to work on your goal(s). At least one should be something that you can do every day.

(Be sure to print this page out or write these steps down somewhere before you hit the submit button so you can refer to them later.)

IV. PROGRESS
Think of the problem(s) or issue(s) you wanted to resolve when you first came to counselling.

On a scale of 1-30 where
1 = the problem(s) or issue(s) that brought you to counselling are worse than ever and cause you a great deal of distress (i.e. low mood, anger management, marital distress, family conflict, etc.)
and
30 = the problem(s) or issue(s) are fully resolved or you feel you are doing very well
use the drop down list to the right to indicate how far you feel you have come toward resolving the problem(s) or issue(s).*
IV. PROGRESS
Think of the problem(s) or issue(s) you wanted to resolve when you first came to counselling.

On a scale of 1-30 where
1 = the problem(s) or issue(s) that brought you to counselling are worse than ever and cause you a great deal of distress (i.e. low mood, anger management, marital distress, family conflict, etc.)
and
30 = the problem(s) or issue(s) are fully resolved or you feel you are doing very well
use the drop down list to the right to indicate how far you feel you have come toward resolving the problem(s) or issue(s).*

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 enter the word that you see below.

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

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