1. Are you:*

2. Type of Therapy:*

3. Affiliate:*

4A. I accomplished what I came to therapy for:*

5. The work completed has made a difference in my life:*

8. I have seen overall improvement in these areas due to therapy (check all that apply):*

9. Area’s in my life I still wish to improve:*

10. I participated in therapy:*

11A. I felt my therapist was skilled in the area I was seeking support:*

12A. I would recommend a friend seeking services in the future:*

13A. I would return for services if needing support again in the future. *

15. I give permission to post non identifying positive feedback on social media to support others seeking similar services:*

16. I would like my feedback to remain anonymous to the treating therapist:*