Symptom Follow-up and Client Satisfaction Survey — Periodic (Every 3-4 Sessions)

Thank-you for filling out this speedy, client satisfaction survey about your progress and experience at Cobb & Associates Inc.

Taking the time to fill out this survey, which is ideally completed every three to four sessions, will greatly assist your therapist in knowing what is working well in counselling, and what, if anything needs to be adjusted in the way your therapy is conducted to help you achieve your goals.

As with all client information, your responses will be kept strictly confidential. We will need some type of identifier from you so that we can match your responses with your case that we have on file. This identifier could be your case ID number (which you'll find on a recent invoice), or the date and time of your last session, or the first three letters of your last name and first initial, or some other identifier that you have pre-arranged to use with your therapist.

If you prefer, you can complete this survey by hardcopy (click here) and simply bring it with you to your next session, or fax it to us at (403) 255-8570 (confidential fax).

This survey should take only about 5 minutes to complete (longer if you add comments, which can be very helpful to your therapist) or 44 clicks of your mouse. If you would like to retain a copy, please print this page on your browser before you submit 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 (DDMMYY0900), or you could use the first 3 letters of your last name and first initial, or some other identifer you have pre-arranged with your therapist.)*
Nathan Cobb
Russ Millington
Diane Gibson
Erla Christens
Shezlina Haji
(If you are coming with your spouse or partner, this helps us to identify you further.)*
Male
Female
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 feel 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 is 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 am learning in counselling are helping me to make positive changes.*
1 Strongly Disagree
2 Disagree
3 Partly Agree, Partly Disagree
4 Agree
5 Strongly Agree
Comment (Optional)


34. I have gained some new insights that have 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 am trying out new patterns of behavior that are helping me.*
1 Strongly Disagree
2 Disagree
3 Partly Agree, Partly Disagree
4 Agree
5 Strongly Agree
Comment (Optional)


36. In our sessions we are covering what is important to me.*
1 Strongly Disagree
2 Disagree
3 Partly Agree, Partly Disagree
4 Agree
5 Strongly Agree
Comment (Optional)


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


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


39. Counselling is helping me improve the quality of my life.

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

Counselling is helping 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 has been very helpful so far.*
1 Strongly Disagree
2 Disagree
3 Partly Agree, Partly Disagree
4 Agree
5 Strongly Agree
Comment (Optional)


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


42. Is there anything that would make the process more helpful or useful to you?

(i.e. Are there topics you wish your and your therapist were discussing, things you wish your therapist would do more of or less of, approaches that aren't working, etc..)



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