Your response to this evaluation form is extremely important to us. We are interested in your honest opinions, whether they are positive or negative. Your comments and suggestions assist us in monitoring and in improving our services. We thank you in advance for your help. The information provided is confidential.


For each statement below, please indicate how much you agree or disagree. Please circle the number representing your feelings about that statement.

(1) Strongly Disagree(2) Disagree(3) Neutral(4) Agree(5) Strongly Agree
Symptoms (presenting problems)
(1) Strongly Disagree
(2) Disagree
(3) Neutral
(4) Agree
(5) Strongly Agree
Attitude
(1) Strongly Disagree
(2) Disagree
(3) Neutral
(4) Agree
(5) Strongly Agree
Self-Control
(1) Strongly Disagree
(2) Disagree
(3) Neutral
(4) Agree
(5) Strongly Agree
Coping Skills
(1) Strongly Disagree
(2) Disagree
(3) Neutral
(4) Agree
(5) Strongly Agree
Relationships
(1) Strongly Disagree
(2) Disagree
(3) Neutral
(4) Agree
(5) Strongly Agree
Insight
(1) Strongly Disagree
(2) Disagree
(3) Neutral
(4) Agree
(5) Strongly Agree
(1) Strongly Disagree(2) Disagree(3) Neutral(4) Agree(5) Strongly Agree
Respectfully
(1) Strongly Disagree
(2) Disagree
(3) Neutral
(4) Agree
(5) Strongly Agree
Compassionately
(1) Strongly Disagree
(2) Disagree
(3) Neutral
(4) Agree
(5) Strongly Agree
Professionally
(1) Strongly Disagree
(2) Disagree
(3) Neutral
(4) Agree
(5) Strongly Agree
Collaboratively
(1) Strongly Disagree
(2) Disagree
(3) Neutral
(4) Agree
(5) Strongly Agree
Competently
(1) Strongly Disagree
(2) Disagree
(3) Neutral
(4) Agree
(5) Strongly Agree
With Understanding
(1) Strongly Disagree
(2) Disagree
(3) Neutral
(4) Agree
(5) Strongly Agree