Therapy Termination Questionnaire Form
Please complete this Therapy Termination Questionnaire Form to help us understand your experience and preferences as your therapy concludes.
Client Name
*
First Name
Last Name
Therapist Name
*
First Name
Last Name
Date of Last Session
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Ending Therapy
*
Achieved my goals
Personal circumstances (e.g., schedule, finances)
Seeking a different approach or provider
Not satisfied with progress
Other
How would you rate your overall experience with therapy?
*
1
2
3
4
5
What progress do you feel you have made during therapy?
*
Are there any goals you feel remain unaddressed?
What are your preferred next steps after ending therapy?
*
No further action needed
Open to future sessions if needed
Would like a referral
Would like resources or recommendations
Other
How would you prefer to be contacted for any follow-up?
*
Email
Phone
No follow-up needed
Other
Additional comments or feedback
Submit
Should be Empty: