1. Default Section

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* 1. Demographic Information

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* 2. General Information

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* 3. How did you hear about our agency?

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* 4. What services did you receive from this therapist?

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* 5. Overall, how do you rate the quality of the following services from your therapist?

  Excellent Good Adequate Fair Poor N/A
Initial Phone Contact or Screening
Intake and Assessment
Early Goal Setting
Developing and Working with Your Goals
Your Collaboration with Your Therapist
Your Therapist's Collaboration with Others
Closure and Ending

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* 6. Overall, how do you rate the quality of the attitude or approach from your therapist?

  Excellent Good Adequate Fair Poor N/A
Listening Skills
Offering Support
Offering Challenges
Offering Educational Materials
Providing Homework
Attending to Details
Starting and Ending on Time
Following Through on Things Promised
Responding to Phone Calls
Responding to Emails
Appreciation of Diversity

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* 7. If you privately paid for your services, how do you rate our fees for services?

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* 8. In general, how do you feel about the following:

  Yes No Maybe
Would you return here for services again?
Would you refer your friends and family here for services?

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* 9. What other comments, suggestions, or feedback would you like to give your therapist?

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* 10. What comments, suggestions, or feedback would you like to give this agency?

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