Client Satisfaction Survey

"*" indicates required fields

Your Name*
2. Using the scale below, please circle the number that best reflects how far you feel you have come in resolving those concerns.
3. Using the next scale below, please select the number that best reflects how far you had expected to come by now:

Please rate how much you have experienced each symptom over the past week.

4. Feeling sad, down or depressed:
5. Avoiding certain people or places:
6. Feeling rejected or unwanted:
8. Loss of interest in activities I normally enjoy:
9. Low energy/feeling tired:
10. Eating too much or not eating enough:
11. Not able to think clearly:
12. Feeling no joy or pleasure in life:
13. Attacks of anxiety:
14. Worrying about things:
15. Angry outbursts:
16. Low self-esteem or low self-confidence:
17. Feeling guilty:
18. Feeling too stressed:
19. Thoughts of suicide:
28. Escaping in drugs or alcohol:
20. Acting out other compulsive behaviors (ie. Gambling, video games, shopping, etc.)
21. Not getting my work done:
22. Feeling unhappy with my workplace (including your home if you work at home):
23. I feel supported and understood during my Intuitive Support sessions:
24. Dana’s style or approach is a good fit for me:
25. The things I am learning during my sessions with Dana are helping me to make positive changes:
26. I have gained some new insights that have changed my views on my situation for the better:
27. I am trying out new patterns of behavior that are helping me:
28. In our sessions, we are covering what is important to me:
29. I (or we) have clear goals for what I (or we) want to accomplish during the session:
30. I am making progress toward reaching those goals:
31. My sessions with Dana are helping me to improve the quality of my life:
32. Overall, my Intuitive Support sessions with Dana have been helpful so far:
This field is for validation purposes and should be left unchanged.