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Patient Feedback Form
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Name:
*
First Name
Last Name
Gender:
Please Select
Male
Female
N/A
Age:
*
About the working relationship with your counsellor:
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
My counsellor listened to me effectively.
My counsellor understood things from my point of view.
My counsellor focussed on what was important to me.
My counsellor accepted what I said without judging me.
My counsellor showed warmth toward me.
My counsellor fostered a safe and trusting environment.
My counsellor egan and finished our sessions on time.
My counsellor followed my lead during our sessions whenever that was important.
My counsellor provided leadership dusring our sessions when/if that was important.
My counsellor challenged me when/if that was important.
About the results of working with your counsellor:
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
The seesions with my counsellor helped me with whatever originally led me to seek counselling.
Any changes which have occurred in me as a result of my counselling have been positive and welcoming.
Overall Satisfaction:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
Counsellor Knowledge
Counsellor Kindness
Level of service provided by counsellor
Waiting Time
Hygiene
How can we improve our service?
Other Comments:
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