Exit this survey

1. Please answer all of the questions below

Question Title

* 1. Please provide your name and email address. Thank you. Please note: it is confidential and secure. You do not have to provide this information if you are uncomfortable. It can remain confidential.

Question Title

* 2. Date of Session:

Date

Question Title

* 3. This was my:

Question Title

* 4. My provider is:

Question Title

* 5. All of us at Stein Counseling and Consulting Services want to do the best job we can. We want to know how we are doing and that means we want to know what YOU think. We would appreciate it if you would take a few minutes to read each question below and tell us how we are doing. Please be HONEST . . . we want to know what we do well and what we can do better so we can do our very best for you! Thank you.

  Strongly Disagree Diagree Agree Strongly Agree
I like meeting with PROVIDER
I think PROVIDER really cares about me as a person
PROVIDER understands me
PROVIDER lets me talk about things that are important to me
When PROVIDER asks me to do something it makes sense to me
I feel better since meeting with PROVIDER
I think things will get better for me now that I have been meeting with PROVIDER
PROVIDER treats me with respect
I know PROVIDER is here to help me become a healthier person
If I had a friend who needed help, I would tell him or her to see PROVIDER
If I needed more help in the future I would want PROVIDER to help me again

Question Title

* 6. The session began on time

Question Title

* 7. The session ended on time

Question Title

* 8. May we contact you with questions regarding your survey?

T