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Client Satisfaction Survey
Your Name
*
First
Last
Your Email
*
1. List the concerns that first brought you to try my intuitive therapy program. What was going on in your life that wasn’t working for you? What were you hoping to achieve?
*
2. Using the scale below, please circle the number that best reflects how far you feel you have come in resolving those concerns.
No Change or Worse
Some Improvement
Moderate Improvement
Much Improvement
Mostly Resolved
Resolved
3. Using the next scale below, please select the number that best reflects how far you had expected to come by now:
No Change or Worse
Some Improvement
Moderate Improvement
Much Improvement
Mostly Resolved
Resolved
Please rate how much you have experienced each symptom over the past week. Note: the first six symptoms relate specifically to your relationship with your spouse or partner.
4. Not speaking to each other:
None
A Little
Moderate
A Lot
Extreme
5. Having bad arguments:
None
A Little
Moderate
A Lot
Extreme
6. Lack of trust:
None
A Little
Moderate
A Lot
Extreme
7. Lack of intimacy:
None
A Little
Moderate
A Lot
Extreme
8. Engaging in harsh, impatient, cutting or attacking language and speech with each other:
None
A Little
Moderate
A Lot
Extreme
9. Feeling lonely in the relationship:
None
A Little
Moderate
A Lot
Extreme
10. Lack of affection and caring between each other:
None
A Little
Moderate
A Lot
Extreme
11. Feeling unhappy about the relationship overall:
None
A Little
Moderate
A Lot
Extreme
12. Feeling sad, down or depressed:
None
A Little
Moderate
A Lot
Extreme
13. Avoiding certain people or places:
None
A Little
Moderate
A Lot
Extreme
14. Feeling rejected or unwanted:
None
A Little
Moderate
A Lot
Extreme
14. Feeling rejected or unwanted:
None
A Little
Moderate
A Lot
Extreme
15. Loss of interest in activities I normally enjoy:
None
A Little
Moderate
A Lot
Extreme
16. Low energy/feeling tired:
None
A Little
Moderate
A Lot
Extreme
18. Eating too much or not eating enough:
None
A Little
Moderate
A Lot
Extreme
19. Not able to think clearly:
None
A Little
Moderate
A Lot
Extreme
20. Feeling no joy or pleasure in life:
None
A Little
Moderate
A Lot
Extreme
21. Attacks of anxiety:
None
A Little
Moderate
A Lot
Extreme
22. Worrying about things:
None
A Little
Moderate
A Lot
Extreme
23. Angry outbursts:
None
A Little
Moderate
A Lot
Extreme
24. Low self-esteem or low self-confidence:
None
A Little
Moderate
A Lot
Extreme
25. Feeling guilty:
None
A Little
Moderate
A Lot
Extreme
26. Feeling too stressed:
None
A Little
Moderate
A Lot
Extreme
27. Thoughts of suicide:
None
A Little
Moderate
A Lot
Extreme
28. Drinking too much or abusing drugs (street drugs or prescribed drugs):
None
A Little
Moderate
A Lot
Extreme
29. Acting out other compulsive behaviors (ie. Gambling, video games, sex, porn, shopping, etc.)
None
A Little
Moderate
A Lot
Extreme
30. Not getting my work done:
None
A Little
Moderate
A Lot
Extreme
31. Feeling unhappy with my workplace (including your home if you work at home):
None
A Little
Moderate
A Lot
Extreme
32. I feel supported and understood during my intuitive therapy session:
Strongly Disagree
Disagree
Partly Agree
Agree
Strongly Agree
Comment:
33. Dana’s style or approach is a good fit for me:
Strongly Disagree
Disagree
Partly Agree
Agree
Strongly Agree
Comment:
34. The things I am learning during my sessions with Dana are helping me to make positive changes:
Strongly Disagree
Disagree
Partly Agree
Agree
Strongly Agree
Comment:
35. I have gained some new insights that have changed my views on my situation for the better:
Strongly Disagree
Disagree
Partly Agree
Agree
Strongly Agree
Comment:
36. I am trying out new patterns of behavior that are helping me:
Strongly Disagree
Disagree
Partly Agree
Agree
Strongly Agree
Comment:
37. In our sessions, we are covering what is important to me:
Strongly Disagree
Disagree
Partly Agree
Agree
Strongly Agree
Comment:
38. I (or we) have clear goals for what I (or we) want to accomplish during the intuitive therapy:
Strongly Disagree
Disagree
Partly Agree
Agree
Strongly Agree
Comment:
39. I am making progress toward reaching those goals:
Strongly Disagree
Disagree
Partly Agree
Agree
Strongly Agree
Comment:
40. My sessions with Dana are helping me to improve the quality of my life:
Strongly Disagree
Disagree
Partly Agree
Agree
Strongly Agree
Comment:
41. Overall, my intuitive therapy sessions with Dana have been helpful so far:
Strongly Disagree
Disagree
Partly Agree
Agree
Strongly Agree
Comment:
42. So far, what has been most helpful or what have you liked the most about your intuitive therapy sessions:
43. How are Dana’s intuitive therapy sessions different than other modalities or approaches you’ve tried in the past:
44. Is there anything that would make the process more helpful or useful to you? (Are there topics you wish we were discussing more, things you wish Dana would do more or less of, approaches that aren’t working as well as other, etc.)
45. Please add any other comments you wish to make: