Date:

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* 1. Date:

Please mark the type of therapy you received:

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* 2. Please mark the type of therapy you received:

Please mark the most appropriate response. Mark all that apply.
I would refer a friend or family member to Jazmin if they were experiencing an issue:

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* 3. Please mark the most appropriate response. Mark all that apply.
I would refer a friend or family member to Jazmin if they were experiencing an issue:

Briefly describe your original reason for seeking therapy:

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* 4. Briefly describe your original reason for seeking therapy:

What was most helpful?

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* 5. What was most helpful?

What was least helpful?

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* 6. What was least helpful?

If you are comfortable doing so, please provide a few brief comments that you would tell others about me as a therapist:

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* 7. If you are comfortable doing so, please provide a few brief comments that you would tell others about me as a therapist:

May I use your comments on my website, without including any of your identifying information?

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* 8. May I use your comments on my website, without including any of your identifying information?

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