New Client Feedback Form

At Together Couples Counseling, your feedback matters!

We value your opinion and we always want to improve our services. We appreciate the opportunity to work with you!

Note: your answers are confidential and will not be shared with your therapist.

How would you rate your experience on a scale of 1-10, with 10 being Excellent

Selected Rating: 5

How satisfied are you with the prompt response to your email/call *

• Unsatisfied
• Neutral
• Satisfied

How satisfied are you with the scheduling of an initial appointment *

• Unsatisfied
• Neutral
• Satisfied

How satisfied are you with the waiting room experience *

• Unsatisfied
• Neutral
• Satisfied

My therapist began and ended our session on time? *

• Yes
• No

My therapist was a good listener *

• Disagree
• Neutral
• Agree

I felt heard and understood by my therapist *

• Disagree
• Neutral
• Agree

The therapist attended to both of our perspectives and feelings about the struggles in our relationship (for couples) *

• Disagree
• Neutral
• Agree

How likely are you to return for a second appointment *

• Unlikely
• Neutral
• Likely

How likely are you to recommend your therapist to others *

• Unlikely
• Neutral
• Likely

How likely are you to recommend TCC to others *

• Unlikely
• Neutral
• Likely

Additional comments or suggestions

Please let us know if there are any changes we can make that would improve your counseling experience.

Your Name

First

Last

Please leave your name and phone or email so we can get back to you!

Your Email

Your Phone Number

Phone

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