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.)*
(If you are coming with your spouse or partner, this helps us to identify you further.)*

6. Not talking to each other.*

7. Having bad arguments.*

8. Lack of trust between us.*

9. Feeling lonely in the relationship.*

10. Lack of affection and caring between us.*

11. Feeling unhappy about our relationship overall.*

12. Feeling sad, down or depressed.*

13. Avoiding certain people or places.*

14. Loss of interest in activities I normally enjoy.*

15. Low energy / feeling tired.*

16. Sleep problems (not falling asleep, not staying asleep, or early waking).*

17. Eating too much or not eating enough.*

18. Not able to think clearly.*

19. Feeling no joy or pleasure in life.*

20. Attacks of anxiety.*

21. Worrying about things.*

22. Angry outbursts.*

23. Low self-esteem or low self-confidence.*

24. Feeling guilty.*

25. Feeling too stressed.*

26. Thoughts of suicide.*

27. Drinking too much or abusing drugs (i.e. street drugs or prescribed medications).*

28. Acting out other compulsive behaviors (i.e. gambling, sex, porn, shopping).*

29. Not getting my work done.*

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).*

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

Comment (Optional)

32. The therapist's approach or style is a good fit for me.*
Comment (Optional)

33. Things I am learning in counselling are helping me to make positive changes.*
Comment (Optional)

34. I have gained some new insights that have changed my views on my situation for the better. *
Comment (Optional)

35. I am trying out new patterns of behavior that are helping me.*
Comment (Optional)

36. In our sessions we are covering what is important to me.*
Comment (Optional)

37. I (or we) have clear goals for what I (or we) want to accomplish in counselling.*
Comment (Optional)

38. I am (or We are) making progress toward reaching those goals.*
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.*
Comment (Optional)

40. Overall, counselling has been very helpful so far.*
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.