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Final Symptom Follow-up and Client Satisfaction Survey

Please use this final client satisfaction survey and feedback form to give feedback about the counselling services you received at Cobb & Associates Inc.. Your responses will provide important information about how services can be improved in the future. This form is meant to be completed after you have concluded counselling services and have no more scheduled visits.

If you prefer, you can complete this survey by hardcopy (click here) and return the completed survey to me by email, mail or by confidential fax at (403) 255-8570.

As with all client information, your responses will be kept strictly confidential. We will need some type of identifier that will help us match your responses with your case that we have on file. This could be your Case ID number (which you'll find on a recent invoice), or the date and time of your last session if you know it, or your last name and first initial, an email address, or some other identifier that we can use to match your responses. Please refer to the privacy policy for Cobb & Associates Inc. if you have any questions about privacy and your personal information.

It should take about 5 minutes to complete or 48 clicks of your mouse (more if you wish to add comments). You will need to finish what you intend to submit in one sitting as you cannot save a partially completed form and come back to it later to continue working on it. If you would like to retain a copy, please print this page on your browser before submitting the survey.

Please note that all fields followed by an asterisk must be filled in.
This could be a Case ID number which you'll find on a recent invoice, or the date and time of your last session if you know it, or you could use the first three letters of your last name and first initial, or some other identifier that you have pre-arranged with your therapist.*
(If you came with your spouse or partner, this helps us to identify you further.)*


6. Not talking to each other.*


7. Having bad arguments.*


8. Lack of trust between us.*


9. Feeling lonely in the relationship.*


10. Lack of affection and caring between us.*


11. Feeling unhappy about our relationship overall.*


12. Feeling sad, down or depressed.*


13. Avoiding certain people or places.*


14. Loss of interest in activities I normally enjoy.*


15. Low energy / feeling tired.*


16. Sleep problems (not falling asleep, not staying asleep, or early waking).*


17. Eating too much or not eating enough.*


18. Not able to think clearly.*


19. Feeling no joy or pleasure in life.*


20. Attacks of anxiety.*


21. Worrying about things.*


22. Angry outbursts.*


23. Low self-esteem or low self-confidence.*


24. Feeling guilty.*


25. Feeling too stressed.*


26. Thoughts of suicide.*


27. Drinking too much or abusing drugs (i.e. street drugs or prescribed medications).*


28. Acting out other compulsive behaviors (i.e. gambling, sex, porn, shopping).*


29. Not getting my work done.*


30. Feeling unhappy with my workplace (including your home if you work at home or your daily household work if you do not have paid work outside the home).*

31. I felt supported and understood by the therapist.*
Comment (Optional)


32. The therapist's approach or style was a good fit for me.*
Comment (Optional)


33. Things I learned in counselling helped me to make positive changes.*
Comment (Optional)


34. I gained new insights that changed my views on my situation for the better.*
Comment (Optional)


35. I tried out new patterns of behavior in our sessions and between sessions that did help me.*
Comment (Optional)


36. In our sessions we did cover what was important to me to talk about.*
Comment (Optional)


37. I (or we) had clear goals for what I (or we) wanted to accomplish in counselling.*
Comment (Optional)


38. I (or We ) made progress toward reaching those goals.*
Comment (Optional)


39. Counselling helped me improve the quality of my life.

(For couples or family therapy, please answer this statement instead):

Counselling helped us improve the quality of our lives together.*
Comment (Optional)


40. Overall, counselling was very helpful to me (or us).*
Comment (Optional)


41. I would come back to see the therapist again if the need arose.*
Comment (Optional)


42. I would recommend the services of Cobb & Associates Inc. without reservation.*
Comment (Optional)


43. What was most helpful to you or what did you like the most about the counselling services you received?


44. Was there anything that disappointed you about counselling or that would have made the process more helpful or useful to you?

(i.e. Were there topics you wished you and your therapist had discussed, things you wished the therapist had done more of or less of, approaches that were not working, etc..)



45. Please check one of the statements below that best matches your primary reason for ending counselling.


Please feel free to elaborate here, if desired:


46. Please add any other comments you wish to make here before submitting this form.