Client Feedback Opportunity

Client Feedback Opportunity

Initial Contact:

Counselor:

Office Environment:

Financial:

Additional Comments:

Optional Information:

The purpose of this questionnaire is to ensure that every Wellspring client receives a quality counseling experience. We appreciate your investment of time to let us know how we are doing.

Please be assured that your responses are anonymous.

Directions:
To rate Wellspring using a scale of 1-5 (1=Low, 3=Average, 5=High) , please use mouse to "click" on circle below the number you wish to select.

For comments, place cursor in blank space and begin typing.

Initial Contact:	NA	1	2	3	4	5
1) Was your phone call returned promptly?
Comments:

2) Were your questions answered to your satisfaction?
Comments:

3) Were you treated with respect and compassion?
Comments:

Counselor:
1) What was the name of your counselor?

1b) How many counseling sessions did you attend?

	NA	1	2	3	4	5
2) Was your counselor able to accommodate you with hours and location which were convenient for you?
Comments:

3) Was your counselor caring and compassionate?
Comments:

4) Did your counselor provide an appropriate balance of Biblical and practical help?
Comments:

5) Was your counselor professional and considerate ? (i.e., on time for appointments, prompt in returning phone calls, keeping scheduled appointments, etc.)
Comments:

6) Have you experienced healing through your counseling experience?
Comments:

7) Would you refer this counselor to a friend? Why or why not? Yes No
Comments:

Optional Information:
Client Name:

If you would like to discuss any of your concerns with a Wellspring staff member (other than your counselor), please feel free to contact us at 636.449.1250 or provide us with your contact information below:

Telephone Number:
E-mail Address:

Before submitting this form, please type the characters displayed above:

Healing Hearts • Restoring Relationships • Liberating Lives

Wellspring Christian Counseling
1400 Elbridge Payne Rd., Suite 200, Chesterfield, MO 63017
Office: 636.449.1250
Fax: 636.449.1268
wellspring@wellspringstl.org

Office Environment:

1) Rate the office for comfort, privacy and convenience

2) Rate Wellspring staff for friendliness and helpfulness