We Want to Hear from You

We want to live up to our name, please help us do that.

Please help us reach our goal by providing us with feedback. We will use this information to adapt and improve your journey. This will also help us identify training opportunities for our therapists and other staff. (All answers are ANONYMOUS unless you provide us with your contact information)

Basic Information

Your Experience With Your Therapist and Treatment

My therapist provides me with skills that... select all that apply

I can practice outside of session

I can apply to my life

Are too difficult to practice

Are not interesting to me

Are not doable due to my circumstances

Are too complicated

Do not go with my personality or interests

My therapist reviews my progress,

Always Often Sometimes Rarely Not Applicable

I feel heard, understood, and respected by my therapist

Always Mostly Often Sometimes Rarely

I feel that my therapist addresses my concerns

Always Mostly Often Sometimes Rearely

The approach used by my therapist is a good fit for me

Strongly Agree Agree Neutral Disagree Strongly Disagree

Overall, I believe that I will gain (have gained) skills that will help meet my goals

Strongly Agree Agree Neutral Disagree Strongly Disagree

My overall satisfaction with my therapist is

Exceptional Very Good Average Ordinary Poor

How likely are you to recommend this practice to your friends and family?

Definetly Likely Only if it comes up Unlikely Definitely not

Share your journey with us!

How has therapy helped you? What is different in your life? What improvements have you made?

Please tell us if there is something we could change or improve (what can we do different?)

(OPTIONAL) If you would like us to follow up with you to discuss your experience, fill out your contact information below.

Yes, please follow up with me to discuss my experience

Patient name

Phone number

Your information will be encrypted.

We Want to Hear from You

We want to live up to our name, please help us do that.

Basic Information

Your Experience With Your Therapist and Treatment

Share your journey with us!

(OPTIONAL) If you would like us to follow up with you to discuss your experience, fill out your contact information below.

We want to live up to our name, please help us do that.

Authentic Journey, LLC