Take Our Survey!

Rest assured, any comments you leave here will remain anonymous and will not be shared with anyone outside the company.

Name

Gender

Age

Date of Visit

Counselor

Please answer the following questions using this scale:
1 - Not at all    2 - Somewhat    3 - Yes    4 - Very much

Was today's session helpful?

1  

2  

3  

4  

Are you resolving your problem?

1  

2  

3  

4  

Are you and your therapist a good fit?

1  

2  

3  

4  

Did the office staff treat you with respect?

1  

2  

3  

4  

Are you seen often enough?

1  

2  

3  

4  

Comments

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