Online vs. In-Person Services Survey

Reflective Counseling Invites You to Submit Feedback

This form relates to service delivery methods – either in-person or online. You may complete this form whenever you’d like.

This feedback form will help your therapist develop and improve the services offered to you and others. We ask that you leave your name so that we can follow up with you directly.

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For the following questions, Yes (I would) or No (I wouldn’t) answers are sufficient. Feel free to respond with more details if you wish.

If in-person individual therapy services were provided I would take advantage of them.

If in-person group therapy services were provided I would take advantage of them.

If in-person support group therapy services were provided I would take advantage of them.

If in-person parenting services were provided I would take advantage of them.

Overall, I would prefer in-person services over telehealth services.

I would be willing to wear a face mask in the waiting room and provide a vaccination card prior to therapy in order to receive in-person services.

If I decided to attend in-person services, I would be willing to sign a COVID-19 Risk Acknowledgment Form; a statement acknowledging that you understand the risk of potential infection of in-person services and accept the responsibility of the potential risk of infection.