UNO Counseling & Career Center: Counseling Feedback Survey

	Please mark the appropriate field for each of the following statements. If you are still in counseling, please evaluate the sessions up to this point in time. All responses are confidential. Thank you for your feedback.

1.	I would rate my counselor as:*
	Very Attentive Attentive Neutral Inattentive Very Inattentive

2.	I would rate my involvement in counseling as:*
	Very Involved Somewhat Involved Neutral Somewhat Uninvolved Not Involved at All

3.	I believe my counseling sessions were:*
	Strictly Confidential Somewhat Confidential Neutral Somewhat Unconfidential Not Confidential at All

4.	Overall, my counseling experience was:*
	Very Positive Positive Neutral Negative Very Negative

5.	The likelihood I would recommend my counselor to a friend is:*
	Very Likely Likely Neutral Unlikely Very Unlikely

6.	I have made positive changes in the problem area for which I sought counseling:*
	Strongly Agree Agree Neutral Disagree Strongly Disagree

7.	Overall, I would rate my counselor as:*
	Very Effective Effective Neutral Ineffective Very Ineffective

8.	The service provided by the receptionist/secretary was:*
	Very Satisfactory Satisfactory Neutral Unsatisfactory Very Unsatisfactory

9.	In which ways was counseling helpful? Please mark all that apply:* Select at least 1 and no more than 6.
	I've been listened to.    I've clarified my problem.    I’ve felt better about myself.    I’ve felt supported.    Counseling has not been helpful.    Other, please specify

10.	Name of Counselor Seen*

11.	Number of Sessions:* The value must be between 1 and 100, inclusive.

12.	Were you provided with a referral for counseling outside of UNO Counseling Services?*
	Yes No

13.	If you received a referral, were you satisfied you received it?
	Yes No

14.	Comments about receiving a referral:

15.	Please indicate the types of problems and concerns for which you sought counseling. (Mark all that apply.)* Select at least 1 and no more than 17.
	Dating    Spouse/Partner    Roommate(s)    Friend(s)    Parent(s)    Sibling(s)    Other Family    Faculty/Staff    Employer    Depression    Anxiety    Alcohol/Drugs    Eating Problems    Academic Problems    Career Concerns    Job/Occupation    Sexual Concerns    Other, please specify

16.	Please make any additional comments about our services.

17.	Age*

18.	Gender*

19.	Race*

20.	Marital Status*

21.	Academic Status (freshman, sophomore, etc.)*

22.	College/Department*