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 *

Gender * 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
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