Looking back over the past few weeks, including today, help us understand how we did in the following areas.

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* 1. Today's Date

Date

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* 2. Information

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* 3. Counselor

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* 5. Relationship

I did not feel heard, understood and respected I felt heard, understood and respected
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 6. Goals and Topics

We did not work on or talk about what I wanted to work on and talk about We worked on and talked about what I wanted to work on and talk about
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 7. Approach or Method

The therapist's approach is not a good fit for me The therapist's approach is a good fit for me
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 8. Overall

I did not enjoy my stay I enjoyed my stay
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 9. Is there anything else you would like us to know?

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* 10. Would you like us to contact you regarding your feedback?

Institute for the Study of Therapeutic Change
www.talkingcure.com
© 2000, Scott D. Miller and Barry L. Duncan

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