Client-Counsellor/Mediator/Supervisor Feedback

The following form (the “Session Rating Scale”) allows you an opportunity to provide feedback to your counsellor/mediator/supervisor after your session has finished. This will help your counsellor/mediator/supervisors professional development as well as helping to improve the service offered to you and others.

Your Name:
Your Email:
Phone Number:
Session Date:
Session Time:

Session Rating Scale

Please rate your counselling / mediation / supervision session by placing the slider with your mouse (left click and drag along the continuum) for each statement, and place the slider at the point that best represents your counselling, mediation, or supervision experience. The continuum measures client response in increments of 1 millimetre, so you may place the slider at any point along the continuum.

Relationship
I did not feel heard, understood, and respected.		I felt heard, understood, and respected.
Goals and Topics
We did not work on or talk about what I wanted to work on and talk about.		We worked on and talked about what I wanted to work on and talk about.
Facilitator Approach or Method
The facilitator's approach is not a good fit for me.		The facilitator's approach is a good fit for me.
Overall
There was something missing in the session today.		Overall, today's session was right for me.

Other Comments

Please use the box below for any other comments on any issues you might like to bring to your counsellor’s attention.

Finally, please confirm you are not a robot by entering the the words displayed below:

Client-Counsellor/Mediator/Supervisor Feedback

Session Rating Scale

Relationship

Goals and Topics

Facilitator Approach or Method

Overall

Other Comments