1.Please indicate your age or the age of the client.

0-5

6-11

12-17

18-25

26-50

51-65

Above 65

2.What is your providers/counselors name?

3.Therapeutic Empathy

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

My therapist seemed warm, supportive and concerned.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

My therapist seemed trustworthy.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

My therapist treated me with respect.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

My therapist did a good job listening.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

My therapist understood what I felt inside.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

4.Helpfulness of the Session

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

I was able to express my feelings during session.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

I talked about the problems that are bothering me.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

The techniques we used were helpful.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

The approach my therapist used made sense.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

I learned some new ways to deal with my problems.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

5.Satisfaction with Today's Session

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

I believe the session was helpful to me.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

Overall, I was satisfied with today's session.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

6.Your Commitment

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

I plan to do therapy homework before next session.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

I intend to use what I learned in today’s session.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

7.Negative Feelings During the Session

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

At times, my therapist didn't seem to understand how I felt.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

At times, I felt uncomfortable during the session.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

I didn't always agree with my therapist.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

8.Difficulties with the Questions

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

It was hard to answer some of these questions honestly.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

Sometimes my answers didn't show how I really felt inside.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

It would be too upsetting for me to criticize my therapist.

Not at all true

Somewhat true

Moderately true

Very true

Completely true

N/A

9.What did you enjoy LEAST about your session?

10.What did you like the BEST about your session?

11.How often does your therapist cancel or reschedule your appointment:

A great deal

A lot

A moderate amount

A little

None at all

Other (please specify)