Client Satisfaction Survey Your Name* First Last Your Email* 1. List the concerns that first brought you to try my Intuitive Support 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.4. Feeling sad, down or depressed: None A Little Moderate A Lot Extreme 5. Avoiding certain people or places: None A Little Moderate A Lot Extreme 6. Feeling rejected or unwanted: None A Little Moderate A Lot Extreme 8. Loss of interest in activities I normally enjoy: None A Little Moderate A Lot Extreme 9. Low energy/feeling tired: None A Little Moderate A Lot Extreme 10. Eating too much or not eating enough: None A Little Moderate A Lot Extreme 11. Not able to think clearly: None A Little Moderate A Lot Extreme 12. Feeling no joy or pleasure in life: None A Little Moderate A Lot Extreme 13. Attacks of anxiety: None A Little Moderate A Lot Extreme 14. Worrying about things: None A Little Moderate A Lot Extreme 15. Angry outbursts: None A Little Moderate A Lot Extreme 16. Low self-esteem or low self-confidence: None A Little Moderate A Lot Extreme 17. Feeling guilty: None A Little Moderate A Lot Extreme 18. Feeling too stressed: None A Little Moderate A Lot Extreme 19. Thoughts of suicide: None A Little Moderate A Lot Extreme 28. Escaping in drugs or alcohol: None A Little Moderate A Lot Extreme 20. Acting out other compulsive behaviors (ie. Gambling, video games, shopping, etc.) None A Little Moderate A Lot Extreme 21. Not getting my work done: None A Little Moderate A Lot Extreme 22. Feeling unhappy with my workplace (including your home if you work at home): None A Little Moderate A Lot Extreme 23. I feel supported and understood during my Intuitive Support sessions: Strongly Disagree Disagree Partly Agree Agree Strongly Agree Comment:24. Dana’s style or approach is a good fit for me: Strongly Disagree Disagree Partly Agree Agree Strongly Agree Comment:25. 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:26. 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:27. I am trying out new patterns of behavior that are helping me: Strongly Disagree Disagree Partly Agree Agree Strongly Agree Comment:28. In our sessions, we are covering what is important to me: Strongly Disagree Disagree Partly Agree Agree Strongly Agree Comment:29. I (or we) have clear goals for what I (or we) want to accomplish during the session: Strongly Disagree Disagree Partly Agree Agree Strongly Agree Comment:30. I am making progress toward reaching those goals: Strongly Disagree Disagree Partly Agree Agree Strongly Agree Comment:31. My sessions with Dana are helping me to improve the quality of my life: Strongly Disagree Disagree Partly Agree Agree Strongly Agree Comment:32. Overall, my Intuitive Support sessions with Dana have been helpful so far: Strongly Disagree Disagree Partly Agree Agree Strongly Agree Comment:33. So far, what has been most helpful or what have you liked the most about your Intuitive Support sessions:34. How are Dana’s intuitive support sessions different than other modalities or approaches you’ve tried in the past:35. 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.)36. Please add any other comments you wish to make:
