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A moment of your time in responding to our satisfaction survey, helps us improve our service for your future visits and those of others in our practice. Your opinions are welcome and appreciated, and can make a difference, so please take a moment to respond.

Therapy Evaluation Questionnaire

Which psychologist did you work with?

In general, did you make good progress in therapy?
Definite YesYesUnsureNoDefinite No

If you had any concerns about your therapy or dissatisfaction with your psychologist, did you feel your psychologist was open to discussing them with you?
Definite YesYesUnsureNoDefinite No

Do you feel you were treated with respect, courtesy and kindness?
Definite YesYesUnsureNoDefinite No

If you had friends/relatives that you thought would benefit from therapy,
would you refer them to me?
Definite YesYesUnsureNoDefinite No

Have your problems changed for the better or worse as a result of your therapy?
Much WorseWorseNo ChangeBetterMuch Better

Please indicate things in therapy that did not work for you.

Please indicate any concerns you have that were not resolved in therapy.

Please check all those items below that apply to you:
I am in therapy with someone else.I would want to see you again if the need arose.My needs were/are met for the time being.My needs were not met.I would seek a different psychologist if the need arose.

Here are some items I would add to this questionnaire for future use:

If interested in receiving a Newsletter on various topics of psychological interest, please provide an address:
Home address:

Thank you for responding to this questionnaire. Your responses will help us provide a better service to our community.

Optional Information






St Charles | 405 Illinois Avenue, Ste. 2C

Oak Brook | 1200 Harger Road, Ste. 220

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