Client Feedback Form

This form allows you an opportunity to provide feedback to your counselor. This will help your counselor’s professional development as well as help to improve the service offered to others.

You DO NOT need to identify yourself.

Please choose a response that most closely corresponds to how you feel about each statement.

Name of Student Counselor *

Today's Date *

About the Working Relationship with Your Counselor

My counselor listened to me effectively. *

My counselor understood things from my point of view. *

My counselor focused on what was important to me. *

My counselor accepted what I said without judging me. *

My counselor showed warmth toward me. *

My counselor fostered a safe and trusting environment. *

My counselor began and finished our sessions on time. *

My counselor followed my lead during our sessions whenever that was appropriate. *

My counselor provided leadership during our sessions when/if that was appropriate. *

My counselor challenged me when/if that was appropriate. *

About the Results of Working With Your Counselor

The sessions with my counselor helped me with whatever originally led me to seek counseling. *

Any changes which might have occurred in me as a result of my counseling have been positive and welcome. *

Overall Satisfaction

My overall level of satisfaction with the service provided by my counselor is: *

Based on my experience, I would recommend my counselor to others. *

Other Comments

Please use the space below for any other comments you would like to bring to your counselor’s attention. If you include your name in this section, it will be treated as CONFIDENTIAL. *

If you happen to see this, do not fill this field.