Client Satisfaction Survey

Please take a few minutes to give us feedback about your experience at Waterloo Counseling Center.
Your comments will help us improve our services.

Please enter the best description.

Date *

YYYY

Gender *

F M F-M M-F Other

Age Group *

12 or younger 13-18 19-24 25-30 31-40 41-50 51-60 60+

Approximate number of months in therapy *

less than 1 1-3 4-6 7-9 10-12 over 12

Question	Strongly Agree	Agree	No Opinon	Disagree	Strongly Disagree
My first contact with Waterloo was positive *
I felt Waterloo responded to my needs in a timely manner. *
Appointment and scheduling procedures were clearly communicated. *
I felt comfortable with Waterloo's environment (i.e. rooms, furniture, temperature, noise level). *
My counselor listened and understood the concerns I brought to counseling. *
My counselor helped me to clarify the nature of my concerns. *
My counselor helped me develop better ways of coping with the problems, feelings, or situation that brought me to Waterloo. *
I felt that my counselor respected me as a person. *
I trust that my counselor will maintain my confidentiality. *
My counselor seemed genuinely interested in helping me *
I would refer my friends to Waterloo. *
I would recommend my counselor to others. *
I would return for counseling if I felt the need. *
I am better prepared now to work through future challenges. *
My experience at Waterloo has positively affected my life. *
Overall, my counseling was effective. *

Question	High	Medium-High	Medium	Medium-Low	Low
Please rate the overall level of distress that brought you to counseling *
Please rate your level of confidence in your own strengths and resources at the time you stopped counseling. *
Please include any other comments you would like to add about your experience at Waterloo:
Name (optional):
Therapist's Name
Check if we may use your comments (without your name or any identifying information) in our printed materials and website:

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