Client Session Assessment Mental Wellness

On a scale from 1 to 5, 1 beind the lowest and 5 being the highest, how are you feeling today?

1 Rage, Furious 2 Angry, Mad 3 Frustured, Confused, Annoyed, Sad 4 Nervous, Worried, Anxious 5 Happy, Calm, Satisfied, Pleased, Okay

This form allows you an opportunity to provide feedback to your provider after your session is complete. This will help your provider’s professional development as well as helping to improve the services offered to others. You DO NOT need to identify yourself. Please place a mark in the box which is most closely corresponds to how you feel about each statement.

1-Strongly Disagree, 2-Somewhat Disagree, 3-No Strong Feeling, 4-Somewhat Agree, 5-Strongly Agree.



About the Working Relationship With Your Provider

1Strongly Disagree 2Somewhat Disagree 3No Strong Feeling 4Somewhat Agree 5Strongly Agree

About the Results of Working With Your Provider

1Strongly Disagree 2Somewhat Disagree 3No Strong Feeling 4Somewhat Agree 5Strongly Agree

Overall Satisfication

1Strongly Disagree 2Somewhat Disagree 3No Strong Feeling 4Somewhat Agree 5Strongly Agree