Gender * MALE FEMALE
(If you are coming with your spouse, this helps us to identify you further, but it is not required)
THERAPIST * I. OVERALL PORGRESS A.)Think of the problems or issues you wanted to resolve when you first came to counselling. *
Select a number below that best reflects how much improvement you feel you have made in resolving those concerns, thus far.
B.) Select a number below that best reflects the improvements you had expected to make in resolving those concerns, thus far. * II. HELPFULNESS OF THE SESSION A.) On a scale of 1-10 rate how helpful this session was for you. *
(i.e. In terms of feeling heard and understood, creating a plan, fostering hope, understanding the issues better, being able to talk things out, getting unstuck, etc..)
B). What was most helpful about the session for you? * C.) Was there anything that was unhelpful in the session? *
(i.e. Were there topics you wanted to discuss but didn't, things you would like to change about the counselling process, approaches that might work better for you? etc..)
III. NEW LEARNING A.)What did you learn this session that helped you? * B.) explain the reason behind this new learning and how it helped your situation *
Note: This could be a positive shift in your emotions, perspective, behavior, or attitude that creates hope, new possibilities or leads to solutions. Examples include seeing a new perspective, learning something new about yourself, seeing your partner in a different way, letting go of hard feelings, or developing a skill that helps you to accomplish your goals.
IV. CLEAR PLAN "I am starting to have clear ideas about what I need to focus on to resolve the issues that prompted me to seek counseling." * YES NO If you selected "Yes" above, what specifically do you plan to work on? * If you selected "Not Sure" or "No", what question (having to do with your concern or issue) would you specifically like to find an answer to through counselling? *
If you can, please write down two specific action steps you will take—something specific and positive you will do or think about in the coming week—to work on your goal(s). At least one should be something that you can do every day.
(Be sure to print this page out or write these steps down somewhere before you hit the submit button so you can refer to them later.)