Session Feedback Form

Please correct the errors described below.

Please help us provide you with the best care possible by telling us how we’re doing and how we can improve.

This form is encrypted and HIPAA-compliant to ensure your responses remain private and secure.

Appointment Information

Patient name

Clinician name

Appointment date

Questions

How satisfied were you with your appointment? Please select an answer with 1 being completely dissatisfied and 10 being completely satisfied.

1 2 3 4 5 6 7 8 9 10

During my most recent session, we worked on things that are important to me. Please select the response that best reflects your opinion, using the following scale:

Strongly Agree Agree Neutral Disagree Strongly Disagree

The approach used in my most recent session felt comfortable and appropriate for me. Please select the response that best reflects your opinion, using the following scale:

Strongly Agree Agree Neutral Disagree Strongly Disagree

I felt acknowledged, valued, and truly heard during my most recent session. Please select the response that best reflects your opinion, using the following scale:

Strongly Agree Agree Neutral Disagree Strongly Disagree

I feel satisfied with my personal and social relationships (e.g., family, friends, coworkers, or classmates). Please select the response that best reflects your opinion, using the following scale:

Strongly Agree Agree Neutral Disagree Strongly Disagree

Overall, I feel I am doing well emotionally, mentally, and personally. Please select the response that best reflects your opinion, using the following scale:

Strongly Agree Agree Neutral Disagree Strongly Disagree

How likely are you to recommend us to your friends and family? Please select an answer with 1 being not at all likely and 10 being very likely.

1 2 3 4 5 6 7 8 9 10

Is there anything else you'd like us to know about your experience?

Would You Like Us to Follow Up?

If you'd like a member of our team to contact you regarding your feedback, please complete your preferred contact information below and check the box to confirm your request. We respect your privacy and will only use this information to follow up on your feedback.

Phone number

Email address

Yes, please follow up with me to discuss my experience

Thank you for taking the time to share your experience with us.
If you requested a follow-up, please allow 1–2 business days for someone from our team to get in touch.

Your information will be encrypted.

Loading...

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Close

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Drop image file here or click to select file Click here to select image file from your computer

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Use this signature or Cancel

Hushmail

Copyright © 1999-2026 Hush Communications Canada Inc.

Terms of service
Privacy policy

Hide