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Thank you for taking our Follow-Up Survey. Remember to include your name to be entered in the drawing which is our way of showing appreciation for your time.

Thank you.

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* 1. Your name:

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* 2. Your therapist's name:

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* 3. Do you remember why you started services?

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* 4. How are you doing today? (check one)

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* 5. Since ending services, how have your problems or symptoms Changed?

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* 6. If you have been feeling the same or worse, please check all the reasons why:

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* 7. Other reasons:

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* 8. If things have gotten better since ending services, please check all the reasons why:

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* 9. If you have tried other things to help you work through problems and symptoms, please check all that apply:

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* 10. Please rate your therapist on the scale below:

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* 11. Please use the space below to add any comments about what you liked or disliked about your experience with your therapist or with the group practice.

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* 12. To what degree do you believe that depression or anxiety are caused by a "chemical imbalance?"

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