Please indicate who is completing this form: *

Patient

Parent/Legal Guardian

Patient First and Last Name *

First Name

Last Name

Did your Therapist explain things in a way that was easy to understand? *

Please rate your provider from 1 (not at all) to 5 (extremely well)

1 - Did not explained it at all

2

3

4

5 - Explained it very well

Did your Therapist create an environment where you felt safe, valued, heard, and seen? *

Please rate your provider from 1 (not at all) to 5 (very much)

1 - Not at all

2

3

4

5 - Very much

Did you feel comfortable providing feedback to your Therapist about ongoing treatment or voicing any concerns/questions? *

Please rate your provider from 1 (not at all) to 5 (very much)

1 - Not at all

2

3

4

5 - Very much

Did your Therapist arrive to your session on time? *

Please rate your provider from 1 (not at all) to 5 (very much)

1 - Not at all

2

3

4

5 - Very much

Did your Therapist allow time for a full session? *

Please rate your provider from 1 (not at all) to 5 (very much)

1 - Not at all

2

3

4

5 - Very much

How likely is it that you would return to the same Therapist in the future? *

Please rate your provider from 1 (not at all) to 5 (very much)

1 - Not at all

2

3

4

5 - Very much

I would recommend Compassionate Therapy Psychology, and am pleased with the overall services and treatment I have received. *

Please rate your provider from 1 (not at all) to 5 (very much)

1 - Not at all

2

3

4

5 - Very much