Client's Report of Counseling and Therapist Survey

Your feedback is extremely valuable! We want to be sure your experience with I Choose Change and your counselor was helpful. We appreciate you taking the time to fill out this confidential survey.

Sincerely,
Jennifer Slingerland Ryan, Ph.D., LPC-S
Managing Director of I Choose Change PLLC

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* 1. Please give the name of your counselor:

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* 2. Please rate the following:

	Unsatisfactory	Somewhat Satisfactory	Met Expectations	Exceeded Expectations	Outstanding
Overall impression of entire counseling experience:	Overall impression of entire counseling experience: Unsatisfactory	Overall impression of entire counseling experience: Somewhat Satisfactory	Overall impression of entire counseling experience: Met Expectations	Overall impression of entire counseling experience: Exceeded Expectations	Overall impression of entire counseling experience: Outstanding
Overall impression of your counselor:	Overall impression of your counselor: Unsatisfactory	Overall impression of your counselor: Somewhat Satisfactory	Overall impression of your counselor: Met Expectations	Overall impression of your counselor: Exceeded Expectations	Overall impression of your counselor: Outstanding
Ease of scheduling:	Ease of scheduling: Unsatisfactory	Ease of scheduling: Somewhat Satisfactory	Ease of scheduling: Met Expectations	Ease of scheduling: Exceeded Expectations	Ease of scheduling: Outstanding
Professionalism of administrative staff:	Professionalism of administrative staff: Unsatisfactory	Professionalism of administrative staff: Somewhat Satisfactory	Professionalism of administrative staff: Met Expectations	Professionalism of administrative staff: Exceeded Expectations	Professionalism of administrative staff: Outstanding
Professionalism of your therapist:	Professionalism of your therapist: Unsatisfactory	Professionalism of your therapist: Somewhat Satisfactory	Professionalism of your therapist: Met Expectations	Professionalism of your therapist: Exceeded Expectations	Professionalism of your therapist: Outstanding
Usefulness of your counselor's assistance:	Usefulness of your counselor's assistance: Unsatisfactory	Usefulness of your counselor's assistance: Somewhat Satisfactory	Usefulness of your counselor's assistance: Met Expectations	Usefulness of your counselor's assistance: Exceeded Expectations	Usefulness of your counselor's assistance: Outstanding
Effectiveness of your counselor's style:	Effectiveness of your counselor's style: Unsatisfactory	Effectiveness of your counselor's style: Somewhat Satisfactory	Effectiveness of your counselor's style: Met Expectations	Effectiveness of your counselor's style: Exceeded Expectations	Effectiveness of your counselor's style: Outstanding

Please elaborate on your positive or negative experiences:

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* 3. What was most effective in your treatment?

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* 4. Was there anything during your counseling that irritated you or rubbed you the wrong way?

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* 5. What was particularly useful in your counseling session(s)?

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* 6. Would you refer someone to this counselor or office for treatment? Please explain.

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* 7. Please give any general feedback not given above.