Date of Therapy Session *

MM

DD

YYYY

Think of the problems or issues you wanted to resolve when you first came to counseling. Select a number below that best reflects how much improvement you feel you have made in resolving those concerns, thus far. *

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

Select a number below that best reflects the improvements you had expected to make in resolving those concerns, thus far.

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

On a scale of 1-10 rate how helpful this session was for you. (i.e. In terms of feeling heard and understood, creating a plan, fostering hope, understanding the issues better, being able to talk things out, getting unstuck, etc..) *

1 Not very helpful at all

2

3

4

5

6

7

8

9

10 Very Helpful

"I am starting to have clear ideas about what I need to focus on to resolve the issues that prompted me to seek counseling."*

Yes

Not Sure

No