Heartswell Therapy Feedback Form
Thank you for taking the time to give us feedback.  We ask you to give us your name because the only way to improve services is through open and direct conversations.  Your feedback will be provided to your therapist and they will discuss this with you in session.   Please complete this form every 3 months.  Please keep in mind that this form is only as confidential as email.  Please do not include your last name or any other identifying information such as age, # or names of children, occupation, etc.  Thanks!
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Email *
First Name Only or Initials
Provider
Frequency and duration of your work with your therapist to date:
Do you feel symptom relief?
Minimal improvement
Dramatic improvement
Clear selection
Do you feel more equipped to handle what life throws at you?
Clear selection
Do you feel more peace?
Clear selection
Do you feel more hope?
Clear selection
Do you have an expanded awareness of self and others?
Clear selection
Do you have an expanded window of tolerance (the space between stimulus and response, ability to slow yourself down)?
Clear selection
Have your relationships improved?
Clear selection
Do you feel more connected to you?
Clear selection
Is there anything you wish to talk about that hasn't been raised yet or enough?
What would you be willing/interested in attending outside of your regularly scheduled psychotherapy sessions to enhance the work?  (Mark all that apply.)
Comments pertaining to tele therapy:
Additional comments:
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