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CSI Counseling Services
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Client Feedback Survey Form
Client Feedback Survey Form
Counselor's Name (optional)
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Please answer the following honestly
I felt heard/understood
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Yes
No
I felt my counselor respected me as a person
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Yes
No
The counselor put me at ease so that I could talk about my concerns
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Yes
No
My counselor helps me to process information I give about my situation (1= strongly disagree to 10= Strongly Agree)
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1
2
3
4
5
6
7
8
9
10
Additional questions (check all that apply)
My experience with the Counseling Center has positivley impacted these areas of my life
Academics
Relationships
Emotional regulation
Improved self esteem
Self management skills
Healthier lifestyle
I made positive changes
Other
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If you have stopped your counseling sessions with CSI Mental Health Services, please tell us why
I have not yet stopped my counseling. I am still seeing my CSI therapist.
I felt I had achieved what I initially came in for.
I did not have time in my schedule to continue counseling sessions.
I did not feel my counselor was helpful with my concerns.
I felt overwhelmed with the material we were discussing and didn't want to continue.
I graduated from (or left) CSI and was no longer eligible for services.
Other
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