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Client Feedback Survey

Part I:

Please mark the appropriate field for each of the following statements. If you are still in counseling, please evaluate the sessions up to this point in time. All responses are confidential. Thank you for your feedback.

a. I would rate my counselor as:
Attentive
1
2
3
4
5
6
Inattentive
b. I would rate my involvement in counseling as:
Very Involved
1
2
3
4
5
6
Not Involved
at All
c. I believe the counseling sessions were:
Strictly
Confidential
1
2
3
4
5
6
Not At
All Confidential
d. Overall, my counseling experience was:
Very Positive
1
2
3
4
5
6
Very Negative
e. The likelihood that I would recommend my counselor to a friend is:
Extremely High
1
2
3
4
5
6
Extremely
Low
f. I have made changes in the problem area for which I sought counseling:
Very Significant Change
1
2
3
4
5
6
Insignificant Change
g. Overall, I would rate my counselor as:
Effective
1
2
3
4
5
6
Ineffective
h. Service provided by the receptionist/secretary was:
Very
Satisfactory
1
2
3
4
5
6
Not
Satisfactory
i. In which ways was your counselor helpful? Mark one or more of the following:

I've been listened to

I've clarified my problem

I've felt better about myself

I've felt supported

Counselor was not helpful
Other
Part II:
Name of Counselor Seen:
Number of Sessions:
1. Were you provided with a referral for counseling outside of the UNO Counseling Services today?
Yes No  
2. Were you satisfied receiving this referral?
Yes No  
Comments:
3. What were your reasons for seeking counseling? (mark all that apply)
Relationship Problems
Spouse/Partner
Dating
Roomate
Friend(s)
Parent(s)
Sibling(s)
Other Family Member(s)
Professor/Faculty/Staff
Employer
Other Problems
Depression
Anxiety
Alcohol/Other Drug(s)
Eating Problem
Academic Probation
Career Concerns
Job/Occupation Problem(s)
Other
4. Please make any additional comments about our services:
Part III:
Age:
Gender:
Race:
Marital Status:
University Status
(freshman,etc.):
UNO College/Department:

UNO Counseling Services
Human Performance Center | Room 112 | 2000 Lakeshore Drive | University of New Orleans | New Orleans, LA 70148
Phone: (504) 280-6683 | Fax: (504) 280-6422
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(504) 280-6000 • Toll-Free at (888) 514-4275