Client/Counsellor Feedback
This form allows you an opportunity to provide feedback to your counsellor after your sessions have finished. This will
help your counsellor’s professional development as well as helping to improve the service offered to others.
You DO NOT need to identify yourself.
Please place a mark in the box which most closely corresponds to how you feel about each statement.
How satisfied were you with the Venue?
Totally Unsatisfied
Entirely Satisfied
Clear selection
Was there anything you particularly liked, or did not like, about the venue(s)?
About the Working Relationship With Your Counsellor
Neither agree or disagree
My counsellor listened to me effectively
My counsellor understood things from my point of view
My counsellor focused on what was important to me.
My counsellor accepted what I said without judging me.
My counsellor showed warmth toward me
My counsellor followed my lead during our sessions whenever that was appropriate.
My counsellor provided leadership during our sessions when/if that was appropriate.
Clear selection
About the Results of Working With Your Counsellor
Strongly Agree
Somewhat Agree
Neutral Feeling
Somewhat Disagree
Strongly Disagree
The sessions with my counsellor helped me with whatever originally led me to seek counselling
Any changes which might have occurred in me as a result of my counselling have been positive and welcome
Clear selection
Overall Satisfaction
Extremely Dissatisfied
Somewhat Dissatisfied
Somewhat Satisfied
Extremely Satisfied
My overall level of satisfaction with the service provided by my counsellor is:
Clear selection
I would recommend this counsellor to someone else
Clear selection
Other Comments
Please use the space below for any other comments you would like to let your counsellor know of. (If there are any matters which you specifically would not have wanted to discuss with your counsellor in person, your counsellor would be especially glad to know of these.) If you include your name in this section, it will be treated as CONFIDENTIAL.
Can I quote you anonymously? From time to time I provide information to potential clients about what others have said about working with me. Please let me know if you would be happy for me to provide your anonymised feedback to others
Clear selection
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