Parent Feedback Form (Periodic)
This form gives you an opportunity to provide feedback to your child's therapist, Kimberly Bartlett, to aid her in working better with you and your child.
What is your child's first name and initial of last?
Example: Jannae M.
Your answer
What is your relationship to your child?
Kimberly has explained the treatment plan for my child/family including goals and methods.
Methods may include individual play therapy sessions, family therapy sessions, parent meetings, etc.
Strongly Disagree
Strongly Agree
I am in agreement with the approach to treatment.
Strongly Disagree
Strongly Agree
What information would you like to know about your child's play therapy treatment?
Please type in an answer.
Your answer
Parent in Treatment
My level of anxiety/stress about my child’s presenting issues:
Very low
Very high
My level of anxiety/stress about parent consultations:
Very low
Very high
My level of anxiety/stress when applying the skills learned through consultation at home
Very low
Very high
What home activities, parental techniques or recommendations have been most helpful to you?
How often are you using skills and techniques taught or other recommendations provided at home?
The effectiveness of Play Therapy is strongly impacted by parental follow through and consistency.
It is important for me to use the skills I learn in treatment at home.
Strongly Disagree
Strongly Agree
I see my role in my child’s presenting issues.
Strongly Disagree
Strongly Agree
I am able to see how the play therapy skills make a difference for my child when I use them.
Strongly Disagree
Strongly Agree
I am able to understand what my child needs in relationship to his needs, desires, wants, etc.
Strongly Disagree
Strongly Agree
I feel like my child's therapist and I are working in a partnership.
Strongly Disagree
Strongly Agree
Progress in Treatment
The dynamics in my family are changing.
Strongly Disagree
Strongly Agree
I see my child developing new coping skills.
Strongly Disagree
Strongly Agree
I see my child making changes.
Strongly Disagree
Strongly Agree
I understand that my therapist is evaluating progress of my child and will keep me updated regarding a date for termination.
Your therapist will reevaluate your child's progress intermittently and meet with you to discuss progress and a recommended termination date.
Strongly Disagree
Strongly Agree
I am satisfied with services received to date.
Strongly Disagree
Strongly Agree
What could improve your services to date?
Please type an answer.
Your answer
Moving Forward
This next section is about moving forward in treatment.
There are new insights/changes/issues discovered regarding my child or family.
Please type a brief update if applicable. Reserve highly confidential comments for in-person.
Your answer
What I’m looking to learn or talk about in my parent consultation with my child’s therapist:
Please type an answer. Reserve highly confidential comments for in-person.
Your answer
What are any possible barriers to continuing Play Therapy (if applicable)?
Your answer
Is there anything else you'd like to provide feedback about?
Please reserve highly confidential comments for in-person/phone conversations.
Your answer
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