Evaluation Session

Please choose the facility you are receiving services at *

Please indicate your age or the age of the client *

What was your scheduled consultation?

What is your providers/counselors name? *

Therapeutic Empathy *

	Not at all true	Somewhat true	Moderatly true	Very true	Completely true	N/A
My therapist seemed warm, supportive, and concerned.
My therapist seemed trustworthy.
My therapist treated me with respect.
My therapist did a good job listening.
My therapist understood what I felt inside.

Helpfulness of the Session *

	Not at all true	Somewhat true	Moderatly true	Very true	Completely true	N/A
I was able to express my feelings during session.
I talked about the problems that are bothering me.
The techniques we used were helpful.
The approach my therapist used made sense.
I learned some new ways to deal with my problems.

Satisfaction with Today's Session *

	Not at all true	Somewhat true	Moderately true	Very true	Completely true	N/A
I believe the session was helpful to me.
Overall, I was satisfied with today's session.

Your Commitment *

	Not at all true	Somewhat true	Moderatly true	Very true	Completely true	N/A
I plan to do therapy homework before next session.
I intend to use what I learned in today’s session.

Negative Feelings During the Session *

	Not at all true	Somewhat true	Moderately true	Very true	Completely true	N/A
At times, my therapist didn’t seem to understand how I felt.
At times, I felt uncomfortable during the session.
I didn’t always agree with my therapist.

Difficulties with the Questions *

	Not at all true	Somewhat true	Moderately true	Very true	Completely true	N/A
It was hard to answer some of these questions honestly.
Sometimes my answers didn’t show how I really felt inside.
It would be too upsetting for me to criticize my therapist.

What did you like the LEAST about the session? *

What did you like the BEST about the session? *