Your Name (optional)
Date:
Number of sessions:
I would appreciate your feedback about your experience as a client of
my Counselling Service.
Your feedback will be helpful to
me in improving the quality of my service.
Please rate your experience in the
following areas and press the "Submit" button on the bottom of the page to send it to me
.
1) Do you believe that the counselling provided by this service has assisted you to better manage your life?
Yes, No, Somewhat?
2)
How satisfied were you with the overall effectiveness of the service?
‘1’ not at all satisfied, - '2' somewhat satisfied, - '3' satisfied, - or ‘4’ very satisfied
Please enter a corresponding number in the box :
3)
How satisfied were you with the arrangements (contacting me, making appointments
etc)?
‘1’ not at all satisfied, - '2' somewhat satisfied, - '3' satisfied, - or ‘4’ very satisfied
Please enter a corresponding number in the box :
.
4) How satisfied were you with the Meeting Room?
‘1’ not at all satisfied, - '2' somewhat satisfied, - '3' satisfied, - or ‘4’ very satisfied
5) How satisfied were you with the confidentiality of the service?
‘1’ not at all satisfied, - '2' somewhat satisfied, - '3' satisfied, - or ‘4’ very satisfied
Please enter a corresponding number in the box :
6) Would you use this service again if you felt you needed assistance in the future?
7) Were there any aspects of your counselling that were especially useful to you ?
.
8) Was there anything missing from the process that you would like to mention?
.
9)
Do you have any other
comments about the service or suggestions how the service can improve?
.
Would you
like me to contact you to discuss any of your comments?
.
________________ Thank you for your cooperation! Please feel free to contact me in the future ______________
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.