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.

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. Note: the first six symptoms relate specifically to your relationship with your spouse or partner.

4. Not speaking to each other:

5. Having bad arguments:

6. Lack of trust:

7. Lack of intimacy:

8. Engaging in harsh, impatient, cutting or attacking language and speech with each other:

9. Feeling lonely in the relationship:

10. Lack of affection and caring between each other:

11. Feeling unhappy about the relationship overall:

12. Feeling sad, down or depressed:

13. Avoiding certain people or places:

14. Feeling rejected or unwanted:

15. Loss of interest in activities I normally enjoy:

16. Low energy/feeling tired:

18. Eating too much or not eating enough:

19. Not able to think clearly:

20. Feeling no joy or pleasure in life:

21. Attacks of anxiety:

22. Worrying about things:

23. Angry outbursts:

24. Low self-esteem or low self-confidence:

25. Feeling guilty:

26. Feeling too stressed:

27. Thoughts of suicide:

28. Drinking too much or abusing drugs (street drugs or prescribed drugs):

29. Acting out other compulsive behaviors (ie. Gambling, video games, sex, porn, shopping, etc.)

30. Not getting my work done:

31. Feeling unhappy with my workplace (including your home if you work at home):

32. I feel supported and understood during my intuitive therapy session:

Comment:

33. Dana’s style or approach is a good fit for me:

Comment:

34. The things I am learning during my sessions with Dana are helping me to make positive changes:

Comment:

35. I have gained some new insights that have changed my views on my situation for the better:

Comment:

36. I am trying out new patterns of behavior that are helping me:

Comment:

37. In our sessions, we are covering what is important to me:

Comment:

38. I (or we) have clear goals for what I (or we) want to accomplish during the intuitive therapy:

Comment:

39. I am making progress toward reaching those goals:

Comment:

40. My sessions with Dana are helping me to improve the quality of my life:

Comment:

41. Overall, my intuitive therapy sessions with Dana have been helpful so far:

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:

Client Satisfaction Survey

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.

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