Client Feedback Form

Home Client Feedback Form

Thank you for taking a couple of minutes to complete this feedback form. We value your feedback!

The information provided on this form is confidential and will only be reviewed by the Counseling Services of Portland’s Practice Manager and Owners. It will not be shared with your therapist, unless you give us permission at the end of this form to do so.

We want you to get positive results. We want to know what worked well and what we could be doing better.
Name * First Last
Email *
Phone *
Your Therapist's Name (optional)

How would you describe your experience at Counseling Services of Portland?

	Strongly Agree	Somewhat Agree	Neutral	Somewhat disagree	Strongly disagree
The office staff was helpful and caring in providing information and booking my first session.
The office space is inviting and comfortable.
My counselor listens to me effectively
My counselor demonstrates to me that they understand things from my own point of view.
My counselor focuses our sessions on what is important to me
My counselor consistently listens to what I am saying without judging me
My counselor consistently shows warmth towards me
My counselor fosters a safe and trusting environment
My counselor begins and finishes all our session on time
My counselor is able to follow my lead during our sessions whenever it is appropriate
My counselor provides practical guidance throughout our sessions when or if it is appropriate
My counselor’s approach has been a good fit for me so far.
My counselor has helped me identify my goals.
My counselor has helped me reach my goals.

Your Overall Experience With Your Counselor

	Strongly Agree	Somewhat Agree	Neutral	Somewhat disagree	Strongly disagree
The overall service provided by my counselor is excellent
Based on my experience, I would recommend others to work with this counselor.

If you have not returned to counseling, please let us know why:
(you can choose more than one)I haven’t reached my goads and completed my therapy yetMy counselor is fullI can’t afford itIt is not a good time for me to continueMy counselor was not a good fit for me
What else would you like us to know about your experience at Counseling Services of Portland that would help us to make it more comfortable and /or helpful for you or others?
Can our Practice Manager or one of our Owners contact you to follow up on any concerns you have expressed on this form
YesNo
If Yes, would you like us to contact you by phone or email?
PhoneEmail
Would you like to share the information on this form with your therapist?
YesNo
Thank you so very much for your feedback!