Anonymous Feedback Form for this Session

Reflective Counseling Invites You to Submit Anonymous Feedback for Your Latest Session

This form gives you an opportunity to provide feedback to your therapist after your sessions. You may complete this form after each session.

It is recommended that you complete this form at least once every six months.

This feedback form will help your therapist develop and improve the services offered to you and others. You DO NOT need to identify yourself. Please indicate what most closely corresponds to how you feel about each statement.

You may choose to provide your name in the following space or choose to submit this form anonymously. However, it would be appreciated if you completely fill out this form in order to improve services at Reflective Counseling, Inc.

Name (Optional)

In the following question, you may use the following and more: Anxiety, Social Anxiety, Panic Disorder, Depression, PTSD, Personality Disorder, Bipolar Disorder, Adjustment/Life Transition, ADHD, Marriage/Couples Work, Parenting Coaching, Other, Unsure

Why are you seeking therapy?

Approximate Length of Relationship with Therapist

For the following, pick a number 1-10 comparing how much you agree with the statement. 1 means Strongly Disagree, 5-6 are Neutral, 10 is Strongly Agree. You may choose to respond with additional text if you wish.

I feel my therapist listens to me.

My therapist understood things from my point of view.

My therapist focused on what was important to me.

My therapist accepted what I said without judging me.

My therapist showed warmth toward me.

My therapist fostered a safe and trusting environment.

My therapist began and finished our sessions on time.

My therapist followed my lead during our sessions whenever that was appropriate.

My therapist provided leadership during our sessions when/if that was appropriate.

My therapist challenged me when/if that was appropriate.

The sessions with my therapist helped me with whatever originally led me to seek therapy.

Any changes which might have occurred in me as a result of my Counseling have been positive and welcome.

The co-pay collection method (IVY Pay) was easy to navigate.

Accessing the online sessions has been easy to use (Psychology Today).

If there were technical difficulties, my therapist worked quickly to resolve them.

The website design is welcoming.

The website's information was helpful and easy to navigate.

The website accurately describes the services provided.

Based on my experience, I would recommend my therapist to others.

In the following question you may use: Very Satisfied, Satisfied, Somewhat Satisfied, Neutral, Somewhat Dissatisfied, Dissatisfied, Strongly Dissatisfied

Please describe your overall level of satisfaction with the service provided by your therapist:

If you would like to provide additional feedback or provide even more clarification to any of the above responses on this feedback form, please feel free to do so in the following box.

Can Reflective Counseling use comments from this feedback form on the website and advertising ad as testimonial?