During the 3 weeks prior to beginning treatment, how would you rate the state of your overall mental health? *

1 = Excellent, 2 = Very Good, 3 = Good, 4 = Fair, 5 = Poor

1

2

3

4

5

During the 3 weeks prior to beginning treatment, how would you rate the state of the specific mental health issue that brought you to therapy? *

1 = Excellent, 2 = Very Good, 3 = Good, 4 = Fair, 5 = Poor

1

2

3

4

5

At termination of therapy, how would you rate the state of your overall mental health? *

1 = Excellent, 2 = Very Good, 3 = Good, 4 = Fair, 5 = Poor

1

2

3

4

5

At termination of therapy, how would you rate the state of the specific mental health issue that brought you to therapy? *

1 = Excellent, 2 = Very Good, 3 = Good, 4 = Fair, 5 = Poor

1

2

3

4

5

How would you rate the state of your overall mental health right now? *

1 = Excellent, 2 = Very Good, 3 = Good, 4 = Fair, 5 = Poor

1

2

3

4

5

How would you rate the specific mental health issue that brought you here now? *

1 = Excellent, 2 = Very Good, 3 = Good, 4 = Fair, 5 = Poor

1

2

3

4

5

Rate your ability to sustain any positive strides you made here. *

1 = Excellent, 2 = Very Good, 3 = Good, 4 = Fair, 5 = Poor

1

2

3

4

5

Rate the helpfulness of this therapist. *

1 = Excellent, 2 = Very Good, 3 = Good, 4 = Fair, 5 = Poor

1

2

3

4

5