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Post Therapy Outcomes Questionnaire (Client)

Client First Name:

(or Prefer to remain anonymous)
Client Last Name:

(or Prefer to remain anonymous)
Today’s date:
MM slash DD slash YYYY
How many trusted adults do you have in your life who you can talk to about your mental health?
- 0
- 1
- 2 or more
Email
Name of therapist:
How do you identify?
How do you identify?
I made progress toward my goals.
- Strongly agree (5)
- Agree (4)
- Neutral (3)
- Disagree (2)
- Strongly disagree (1)
I am satisfied with the progress I made.
- Strongly agree (5)
- Agree (4)
- Neutral (3)
- Disagree (2)
- Strongly disagree (1)
I can talk to friends or family members about my mental health.
- Strongly agree (5)
- Agree (4)
- Neutral (3)
- Disagree (2)
- Strongly disagree (1)
My mental health improved because of therapy.
- Strongly agree (5)
- Agree (4)
- Neutral (3)
- Disagree (2)
- Strongly disagree (1)
My mental health improved because of other reasons.
- Strongly agree (5)
- Agree (4)
- Neutral (3)
- Disagree (2)
- Strongly disagree (1)
My work situation improved (new job, better job, better hours, better pay or benefits, better attendance)
- Strongly agree (5)
- Agree (4)
- Neutral (3)
- Disagree (2)
- Strongly disagree (1)
My education improved (went back to school, stayed in school, better attendance)
- Strongly agree (5)
- Agree (4)
- Neutral (3)
- Disagree (2)
- Strongly disagree (1)
My overall well-being improved (general sense of well-being, life satisfaction).
- Strongly agree (5)
- Agree (4)
- Neutral (3)
- Disagree (2)
- Strongly disagree (1)
My close relationships improved (better communication, less conflict).
- Strongly agree (5)
- Agree (4)
- Neutral (3)
- Disagree (2)
- Strongly disagree (1)
Other relationships improved (work, school, friends)
- Strongly agree (5)
- Agree (4)
- Neutral (3)
- Disagree (2)
- Strongly disagree (1)
My finances improved (more stable, better decision making).
- Strongly agree (5)
- Agree (4)
- Neutral (3)
- Disagree (2)
- Strongly disagree (1)
My therapist respected my culture, spiritual beliefs, and/ or sexuality.
- Strongly agree (5)
- Agree (4)
- Neutral (3)
- Disagree (2)
- Strongly disagree (1)
I was matched with a clinician who met my needs.
- Strongly agree (5)
- Agree (4)
- Neutral (3)
- Disagree (2)
- Strongly disagree (1)
I would recommend this service to a friend/ family.
- Strongly agree (5)
- Agree (4)
- Neutral (3)
- Disagree (2)
- Strongly disagree (1)
How many sessions did you complete (to the best of your memory)?
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- more than 12
How many days in the past month would you say your mental health was not good (difficulty coping)?
Reason therapy ended (check all that apply):
- Met my goals
- Finished allotted number of sessions
- Bad fit with therapist
- Unable to continue therapy due to life circumstances (transportation, scheduling, other)
- Obtained insurance (new benefit)
- Sought services elsewhere
- Other:
We welcome any other comments or feedback about your experience:

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Thank you for submitting an application to the Pro Bono Counseling Project. We will review your application and get back to you in the next 72 hours. Our goal is to match you with a therapist who can meet your needs as soon as possible. In the meantime, check out our website to learn more about the project.