Youth Therapy Feedback Survey Form
Please share your feedback about your recent youth therapy session. Your input helps us improve our services.
What is your role?
*
Youth
Parent/Guardian
Caregiver
Other
Date of your session
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How would you rate your overall experience?
*
1
2
3
4
5
How comfortable and safe did you feel during the session?
*
Not at all
1
2
3
4
Extremely
5
1 is Not at all, 5 is Extremely
How clear was the therapist’s communication?
*
Not clear
1
2
3
4
Very clear
5
1 is Not clear, 5 is Very clear
How much were you able to participate and share your thoughts?
*
Not at all
1
2
3
4
Fully
5
1 is Not at all, 5 is Fully
What helped you most during this session?
What could be improved for future sessions?
Would you recommend this service to others?
*
Definitely not
1
2
3
4
Definitely yes
5
1 is Definitely not, 5 is Definitely yes
Any additional comments?
Submit Feedback
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