Client Pre & Post Evaluation Form

Please take a moment and complete this brief evaluation, which we will use to assess the effectiveness of our services.

1. What is the difficulty that caused you to seek counseling?

2. Please rate your present capacity to respond to this difficulty:
(1=Very stressed with little ability to cope; 10= Not stressed about situation and coping very well)

1       2       3       4       5       6       7       8       9       10

(Low)                                                                        (High)

3. Please rate your present overall life satisfaction:

1       2       3       4       5       6       7       8       9       10

(Low)                                                                        (High)

4. Please rate your present level of distress:

1       2       3       4       5       6       7       8       9       10

(Low)                                                                        (High)

5. How important is it to you that your counselor takes seriously your religious faith perspective?

1       2       3       4       5       6       7       8       9       10

(Not Important)                                                         (Very Important)

6. Would you have been able to see a pastoral counselor without financial assistance? Yes       No

7. Please discuss your overall counseling experience (Answered ONLY at termination of counseling):

8. Additional Comments:

Your comments are appreciated. Personal testimonials are very valuable to the continued work of the Partnership. If we may use your comments in letters or brochures please initial here: ____________

Your name will never be used and will remain confidential.

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