Client Feedback and Needs Questionnaire

We need your feedback so we can ensure that your needs are being met.

This questionnaire is being sent to ensure that your clinical needs are being met and to ensure that we honor your wants and needs as a client.

Note: Your answers are confidential. Any feedback given to your therapist will not identify you and will be general in nature.

Name

First Name

Last Name

Overall, are your needs being met with your current therapist?

YES

How much have you been impacted by your therapist canceling or rescheduling sessions ?

Would you like to be offered another therapist at Life Balance if one is available?

YES

Still Deciding

Would you like a referral for a therapist outside of Life Balance?

YES

Still Deciding

Is there anything you'd like us to know so that we can best meet your needs?