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MENTAL HEALTH SATISFACTION SURVEY
To make sure that you are receiving quality services, please complete this questionnaire.
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Email *
Patient Name *
Therapist Name *
Date
MM
/
DD
/
YYYY
Please answer the following questions about your experience.
To what extent did the therapist:
Help you achieve the purpose for which you sought counseling?
Not At All
Completely
Clear selection
Help you obtain skills that will help you handle future problems?
Not At All
Completely
Clear selection
Understand your needs?
Not At All
Completely
Clear selection
Help you define your goals?
Not At All
Completely
Clear selection
Involve you in the treatment planning
(such as treatment goals and frequency of appointments)?
Not At All
Completely
Clear selection
Respond to your requests for services?
Not At All
Completely
Clear selection
Are you going to continue treatment with this therapist?
Do you have any specific feedback about your treatment and/or your therapist?
A copy of your responses will be emailed to the address you provided.
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