Your Opinion Counts!!

For each of the statements below, circle the word that is closest to how you feel.

1) I feel like (your name here) really listens to me and understands what I am saying.

Never                                 Sometimes                                 Usually                                 Always

2) I feel comfortable and safe when I meet with (your name here). I feel like she cares.

Never                                 Sometimes                                 Usually                                 Always

3) I feel like meeting with (your name here) has helped me talk about my feelings.


I disagree.                    I'm not sure if it helped.                 It helped a little.                 It helped a lot.

4) I look forward to seeing (your name here) and talking about what is going on in my life.

Never                                 Sometimes                                 Usually                                 Always

5) I feel like meeting with (your name here) has helped me sort out some of my feelings.

I disagree.                     I'm not sure if it helped.                 It helped a little.                It helped a lot.

6) What do you like about coming in to talk with (your name here)?


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7) Is there anything you don't like so much about coming to talk to (your name here)?


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8) How do you feel about (your name here) leaving and not meeting with him/her anymore?


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9) What, if anything, will you miss about your time with (your name here)?

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10) Do you have any additional feedback about your time with (your name here)?

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