[ FORM 47 —Use the top of this page for your letterhead.] Follow-Up Questionnaire 1 ID #: Therapist’s name: Today’s date: Date of last session: 61 22 4 What is your gender? q Male q Female How old are you? years For each question, please circle a number to show how much you agree with the statement. Use a scale from1=“ I completely disagree ” to 7 = “I completely agree. ” If the statement does not apply to you or your experience, please circle NA. Disagree Agree 1. I was treated with courtesy and respect by the secretary/receptionist and other staff. 1234567 NA 2. I was treated with courtesy and respect by the therapist. 1234567 NA 3. I felt the therapist was appropriately concerned about my problem. 1234567 NA 4. The therapist seemed well trained and skilled in helping me with my concerns. 1234567 NA 5. The therapist helped me to be comfortable enough to express what I was thinking and/or feeling most of the time.
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This note was uploaded on 07/01/2010 for the course COUN 6682 A and taught by Professor All during the Spring '10 term at Walden University.