Date of Therapy Session
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MM
DD
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PART ONE: Your Perception of Overall Progress Think of the concerns you had when you first came to counseling. Using the scale below, please select the number that best reflects how far you feel you have come in resolving those concerns.
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0.0 We have only had 1-2 sessions, too early to tell
0.0 No improvement
0.5
1.0 Some improvement
1.5
2.0 Moderate Improvement
2.5
3.0 Much Improvement
3.5
4.0 Mostly Resolved
4.5
5.0 Resolved
Using the next scale below, please select the number that best reflects how far you had expected to come by now.
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0.0 We have only had 1-2 sessions, too early to tell
0.0 No improvement
0.5
1.0 Some improvement
1.5
2.0 Moderate Improvement
2.5
3.0 Much Improvement
3.5
4.0 Mostly Resolved
4.5
5.0 Resolved
PART TWO: Symptom Checklist Follow-up Please rate how much you have experienced each symptom over the past week. Note: the first six symptoms relate specifically to your relationship with your spouse or partner – if you are single, use the “0” rating. 6. Not talking to each other.
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Having bad arguments
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Lack of trust between us
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Feeling lonely in the relationship
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Lack of affection and caring between us
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Feeling unhappy about our relationship overall
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Feeling sad, down or depressed
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Avoiding certain people or places
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Loss of interest in activities I use to enjoy
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Low energy/feeling tired
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Sleep problems (not falling asleep, not staying asleep, or early waking)
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Eating too much or not eating enough
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Not able to think clearly
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Feeling no joy or pleasure in life
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Attacks of anxiety
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Worrying about things
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Angry outbursts
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Low self-esteem or self-confidence
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Feeling guilty
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Feeling too stressed
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Thoughts of suicide
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Not getting my work done
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Feeling unhappy with my workplace
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PART THREE. Client Satisfaction Survey | I felt supported and understood by the therapist.
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For items #31-40, please indicate how much you agree or disagree with each statement. These statements have to do with your experience at your counselling sessions. On this scale, 1=strongly disagree and 5=strongly agree.
Comment (optional)
The therapist's approach or style was a good fit for me.
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Comment (optional)
Things I learned in counseling helped me to make positive changes in my life.
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Comment (optional)
I gained some new insights that changed my views on my situation for the better.
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Comment (optional)
I tried out new behavior patterns that helped me.
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Comment (optional)
In our sessions, we covered what was important to me.
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Comment (optional)
I had clear goals for what I want to accomplish in counseling.
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Comment (optional)
I made progress toward reaching those goals.
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Comment (optional)
Counseling helped me to improve the quality of my life.
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Comment (optional)
Overall, counseling was very helpful.
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Comment (optional)
Please add any other comments you would like to add before submitting this form.
