Name (Optional)
First Name
Last Name
What is your gender identity?
Woman
Man
Trans Woman
Trans Man
Non-binary
What is your age?
12-17 years old
18-29 years old
30-39 years old
40-49 years old
50-59 years old
60-69 years old
70+ years old
What type of mental health services have you participated in at Untold Stories Psychotherapy?
Individual Therapy
Couples Therapy
Family Therapy
None of the Above
Are you currently receiving services at Untold Stories Psychotherapy?
No, I am a former client
Yes, I am a current client
I am neither a former nor current client
How often were you/are you attending sessions?
Twice a week
Once a week
Once every other week
Once every 3 weeks
Once a month
How long were you/have you been in therapy at Untold Stories Psychotherapy?
Less than a month
1 - 3 months
3 - 6 months
6 - 9 months
9 - 12 months
Roughly a year and a half
Roughly 2 years
Over 2 years
I have not attended any sessions at this practice
What did you initially seek services for? (Select all that apply)
What is your overall level of satisfaction with the services provided by your therapist?
Extremely Unsatisfied
Unsatisfied
Neither Unsatisfied nor Satisfied
Satisfied
Extremely Satisfied
How effective has your work with your therapist been?
Extremely Ineffective
Ineffective
Neither Ineffective nor Effective
Effective
Extremely Effective
How do you feel about you and your therapist's overall work together?
Extremely Negative
Negative
Neither Negative nor Positive
Positive
Extremely Positive
Please indicate how much you agree or disagree with the following statements:
My therapist has provided a safe, trusting, and supportive environment.
I have felt listened to, understood, respected, and cared for by my therapist.
My therapist has consistently shown warmth toward me.
I have felt comfortable discussing my concerns with my therapist.
I haven't felt judged by my therapist for how I am thinking, feeling, or behaving.
My therapist has focused on what is important to me.
I believe my therapist is knowledgeable and competent.
My therapist has provided leadership during our sessions when appropriate.
My therapist has followed my lead during our sessions when it's appropriate to do so.
My therapist has challenged me when it's appropriate to do so.
My work with my therapist has helped me better understand myself and my presenting concern(s).
I have been involved in making decisions regarding the support provided to me.
My work with my therapist has helped me address what initially led me to seek services.
My therapist and I have identified specific goals to be achieved during treatment.
I have felt that any changes that has transpired as a result of my work with my therapist have been positive.
My work with my therapist has met my expectations.
Please indicate how much you agree or disagree with the following statements:
I would like my therapist and I to devote time at the beginning of each session to outline what we will be discussing.
I would like my therapist and I to devote time toward the end of each session to summarize what we discussed.
I would like my therapist to provide me with “homework” between sessions.
I would like more time to express myself during sessions.
I would like more feedback from my therapist during sessions, even if that gives me less time to express myself.
How satisfied are you with the time it takes your therapist to respond to your phone calls or emails?
Extremely Unsatisfied
Unsatisfied
Neutral
Satisfied
Extremely Satisfied
How satisfied are you with the process of booking sessions with your therapist?
Extremely Unsatisfied
Unsatisfied
Neutral
Satisfied
Extremely Satisfied
How satisfied are you with the process of paying for services?
Extremely Unsatisfied
Unsatisfied
Neutral
Satisfied
Extremely Satisfied
How likely are you to recommend Untold Stories Psychotherapy to friends, colleagues, and others?
Extremely Unlikely
Unlikely
Neutral
Likely
Extremely Likely
If you would NOT recommend Untold Stories Psychotherapy, please share your reason(s) why.
What aspects of your work with your therapist have you found to be helpful?
What aspects of your work with your therapist have you found to be unhelpful?
What do you wish occurred more or less often in your work with your therapist?
Is there anything else that you wish to share about your experience with your therapist and/or treatment?
Are you comfortable with Untold Stories Psychotherapy posting anything you might have shared here as an anonymous testimonial?
