1. The problems, feelings, or situation that brought me to therapy are:
__ Much improved
__ Improved
__ About the same
__ Worse
__ Much worse
2. Because of therapy, I understand my problems well enough to manage them in the future.
__ Strongly agree
__ Agree
__ Not certain
__ Disagree
__ Strongly disagree
3. My therapist was:
__ Very helpful
__ Somewhat helpful
__ Neither helpful or unhelpful
__ Somewhat unhelpful
__ Very unhelpful
4. If I needed help in the future, I would feel comfortable calling this therapist:
__ Definitely YES
__ Probably YES
__ Maybe
__ Probably not
__ Definitely not
5. I would recommend this therapist to others who need help:
__ Definitely YES
__ Probably YES
__ Maybe
__ Probably not
__ Definitely not
6. The interest shown by my therapist in helping me to solve my concerns was:
__ Very satisfactory
__ Satisfactory
__ Neither satisfactory or unsatisfactory
__ Unsatisfactory
__ Very unsatisfactory
7. How long has it been since your last visit?
__ Less than 1 month
__ 1 -2 months
__ 3-5 months
__ 6 months or more (how many _____)
8. Treatment ended with this therapist because:
__ The concerns which brought me to therapy were worked out to my
satisfaction.
__ Most of the significant concerns which brought me to therapy were
worked out to my satisfaction. There are some minor problems that we
can now handle.
__ We reached the number of sessions set by my insurance. Significant
problems remained that we did not address.
__ I felt that more treatment would not be helpful at this time, even though
significant problems remained.
__ The therapist felt that more treatment would not be helpful at this time,
even though significant problems remained.
__ There was a change in a work or school schedule that made it
impossible to arrange further appointments.
9. After you received treatment with this therapist, have you received any treatment elsewhere for the same concerns you came here for?
__ YES __ NO
10. I would appreciate any other comments that you would like to share.
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Signature Date
Thank you for your time