Therapy Service Release & Client Review Form
Please provide your feedback about your therapy experience and grant consent for your review to be used by our practice.
Client Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Service
*
-
Month
-
Day
Year
Date
Therapist Name
*
Type of Therapy Received
*
Please Select
Individual Therapy
Couples Therapy
Family Therapy
Group Therapy
Other
Please rate the following aspects of your therapy experience:
*
Rows
Excellent
Good
Fair
Poor
Therapist's professionalism
1
2
3
4
Comfort of the environment
5
6
7
8
Effectiveness of therapy
9
10
11
12
Communication and responsiveness
13
14
15
16
Overall Satisfaction with Therapy Services
*
1
2
3
4
5
What did you find most helpful about your therapy experience?
Do you have any suggestions for improvement?
Would you recommend our therapy services to others?
*
Yes
No
Signature (Please sign to confirm your feedback and consent)
*
Submit Review
Submit Review
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