Coppin State Individual Therapy Survey

Name

First

Last

Email Address

Date of Birth

Session Date

Provider/Therapist

Please rate your level of satisfaction with the following aspects of this program:

	Very Satisfied	Satisfied	Neutral	Unsatisfied	Very Unsatisfied
Provider/Therapist	Very SatisfiedProvider/Therapist Very Satisfied	SatisfiedProvider/Therapist Satisfied	NeutralProvider/Therapist Neutral	UnsatisfiedProvider/Therapist Unsatisfied	Very UnsatisfiedProvider/Therapist Very Unsatisfied
Facility/Physical Environment	Very SatisfiedFacility/Physical Environment Very Satisfied	SatisfiedFacility/Physical Environment Satisfied	NeutralFacility/Physical Environment Neutral	UnsatisfiedFacility/Physical Environment Unsatisfied	Very UnsatisfiedFacility/Physical Environment Very Unsatisfied
Length/Duration of the Session	Very SatisfiedLength/Duration of the Session Very Satisfied	SatisfiedLength/Duration of the Session Satisfied	NeutralLength/Duration of the Session Neutral	UnsatisfiedLength/Duration of the Session Unsatisfied	Very UnsatisfiedLength/Duration of the Session Very Unsatisfied
Session Met Your Needs/Expectations	Very SatisfiedSession Met Your Needs/Expectations Very Satisfied	SatisfiedSession Met Your Needs/Expectations Satisfied	NeutralSession Met Your Needs/Expectations Neutral	UnsatisfiedSession Met Your Needs/Expectations Unsatisfied	Very UnsatisfiedSession Met Your Needs/Expectations Very Unsatisfied

Please identify how much you agree with the following statements:

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
After attending the session I feel motivated to make my mental health a priority	Strongly DisagreeAfter attending the session I feel motivated to make my mental health a priority Strongly Disagree	DisagreeAfter attending the session I feel motivated to make my mental health a priority Disagree	NeutralAfter attending the session I feel motivated to make my mental health a priority Neutral	AgreeAfter attending the session I feel motivated to make my mental health a priority Agree	Strongly AgreeAfter attending the session I feel motivated to make my mental health a priority Strongly Agree
I felt safe and supported during this session	Strongly DisagreeI felt safe and supported during this session Strongly Disagree	DisagreeI felt safe and supported during this session Disagree	NeutralI felt safe and supported during this session Neutral	AgreeI felt safe and supported during this session Agree	Strongly AgreeI felt safe and supported during this session Strongly Agree

How did you feel before your session started today

How do you feel now?

How would you feel about recommending this program to others?

Comments

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