Client Satisfaction Survey Form

1

Your Name (Optional)(Required, if you would like us to follow up with you.)

First Name

Last Name

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2

The Name of Your Therapist* This field is required.

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3

Overall SatisfactionPlease complete your evaluation of your therapy experience with us.

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4

If you needed counseling in the future, would you return to Rum River Counseling?

YESNO

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5

Would you recommend Rum River Counseling to someone who wanted counseling?

YESNO

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6

What did you find MOST helpful about your therapist or your therapy experience at Rum River Counseling?

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7

What did you find LEAST helpful about your therapist or your therapy experience at Rum River Counseling?

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8

Additional comments or ideas on how to improve our services:

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9

Would you like us to follow up with you regarding any concerns?

YESNO

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10

If yes, what is the best way to reach you?

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11

Email

example@example.com

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12

Phone Number

Area Code

Phone Number

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13

Please verify that you are human* This field is required.

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