Form47 - [FORM 47-Use the top of this page for your...

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[ 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: 6 12 24 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 from 1 = “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. 1 2 3 4 5 6 7 NA 2. I was treated with courtesy and respect by the therapist. 1 2 3 4 5 6 7 NA 3. I felt the therapist was appropriately concerned about my problem. 1 2 3 4 5 6 7 NA 4. The therapist seemed well trained and skilled in helping me with my concerns. 1 2 3 4 5 6 7 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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