Group Therapy Client Feedback Form

Group Therapy Client Feedback Form
Thank you for taking the time to fill out this feedback survey. We value your input!
The information you enter on this form is private and will only be seen by us. Unless you give us permission at the bottom of this form, it will not be shared with your therapist.
We want you to achieve positive outcomes. We want to know what went well and where we could improve.
Your Name
First NameLast Name
Your Therapist Name
First NameLast Name
Your Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your Email
example@example.com

How would you evaluate your experience here?

Rows	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied
In providing information and scheduling my initial appointment, the office personnel was courteous and helpful.
The office environment is warm and friendly.
My counselor pays attention to me.
My counselor proves that they comprehend things from my perspective.
My counselor tailors our sessions to my specific needs.
My counselor consistently listens to me without passing judgment.
My counselor is always nice and friendly to me.
My counselor creates a trustworthy and safe environment for me.
My counselor starts and ends our sessions on schedule.
When it's acceptable, my counselor can follow my lead during our sessions.
When and if it is appropriate, my counselor offers practical advice during our sessions.
So far, my counselor's method has worked well for me.
My counselor has assisted me in determining my objectives.
My counselor has assisted me in achieving my objectives.

How would you evaluate your relationship with your counselor in general?
Rows Not Satisfied Somewhat Satisfied Satisfied Very Satisfied
My counselor provides outstanding service in general.
Based on my own experience, I would suggest this counselor to others.
Please explain why you have not returned to counseling, if you haven't:
What else do you want us to know about your visit here that would help us make it more comfortable and/or useful for you or others?
Can one of our owners or our practice manager call you to follow up on any concerns you've raised on this form?
Do you want us to call you or send you an email?
Would you like to give your therapist the information on this form?
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