Client Satisfaction Survey

CLIENT SATISFACTION SURVEY

* Indicates required field

Date of Survey *

Primary Clinician Assigned to Case *

Co-Facilitator Assigned to Case *

Client's Name *

First

Last

Client's Date of Birth *

Client's Address *

Line 1

Line 2

City

State

Zip Code

Country

Name of Person Answering Survey (if other than client) *

First

Last

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Relationship to Client *

How often do you meet with the therapist? *

When was your most recent session with the therapist? *

How satisfied are you with the mental health services that you and/or your child have received?

Choose One *

1. Extremely Dissatisfied 2. Moderately Dissatisfied 3. Somewhat Dissatisfied 4. Somewhat Sastified 5. Moderately Satisfied 6. Extremely Sastisfied

To what degree have you been included in the treatment planning process for yourself and/or your child.

Choose One *

1. Not at All 2. A Little 3. Somewhat 4. Moderately 5. Quite a Bit 6. A Great Deal

To what extent do you feel that your therapist listens to and values your ideas about treatment planning for yourself and/or your child.

Choose One *

1. Not at All 2. A Little 3. Somewhat 4. Moderately 5. Quite a Bit 6. A Great Dea;

To what extent does you and/or your treatment plan include your ideas about you and/or your child's treatment needs?

Choose One *

Not at All A Little Somewhat Moderately Quite a Bit A Great Deal

What other comments/concerns do you have regarding the services you have received from your therapist?

Additional Comments *

Thank you very much for your time and assistance!

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