If you would like to provide feedback in another format (eg. through our website, by email, or by phone) please contact Mercedes Pitters at 519-539-8055 ext.211 or mercedespitters@cmhaoxford.on.ca

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* 1. Date

Date

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* 2. What is your age?

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* 3. What is your sex?

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* 4. I felt heard, understood and respected by my counsellor today.

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* 5. We worked on and talked about a plan for me.

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* 6. Overall, today’s session was useful for me.

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* 7. What did you least like about your Walk-In Counselling experience?

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* 8. What did you like most about your Walk-In Counselling experience?

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* 9. Do you have any ideas or suggestions for Walk-In Counselling?

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* 10. Do you consent to the use of your feedback to be used anonymously for the purposes of promotion and/or advertising of the Walk-In Counselling Program?

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