Web Site K10 Followup Questionaire First Name * Last Name * Date * For all questions, please select the appropriate response for the last 4 weeks. 1. About how often did you feel tired out for no good reason? * Please select the appropriate response from the drop down menu. 1. None of the Time 2. A little of the Time 3. Some of the Time 4. Most of the Time 5. All of the Time 2. About how often did you feel nervous? * Please select the appropriate response from the drop down menu. 1. None of the Time 2. A little of the Time 3. Some of the Time 4. Most of the Time 5. All of the Time 3. About how often did you feel so nervous that nothing could calm you down? * Please select the appropriate response from the drop down menu. 1. None of the Time 2. A little of the Time 3. Some of the Time 4. Most of the Time 5. All of the Time 4. About how often did you feel hopeless? * Please select the appropriate response from the drop down menu. 1. None of the Time 2. A little of the Time 3. Some of the Time 4. Most of the Time 5. All of the Time 5. About how often did you feel restless or fidgety? * Please select the appropriate response from the drop down menu. 1. None of the Time 2. A little of the Time 3. Some of the Time 3. Most of the Time 5. All of the Time 6. About how often did you feel so restless you could not sit still? * Please select the appropriate response from the drop down menu. 1. None of the Time 2. A little of the Time 3. Some of the Time 4. Most of the Time 5. All of the Time 7. About how often did you feel depressed? * Please select the appropriate response from the drop down menu. 1. None of the Time 2. A little of the Time 3. Some of the Time 4. Most of the Time 5. All of the Time 8. About how often did you feel that everything was an effort? * Please select the appropriate response from the drop down menu. 1. None of the Time 2. A little of the Time 3. Some of the Time 4. Most of the Time 5. All of the Time 9. About how often did you feel so sad that nothing could cheer you up? * Please select the appropriate response from the drop down menu. 1. None of the Time 2. A little of the Time 3. Some of the Time 4. Most of the Time 5. All of the Time 10. About how often did you feel worthless? * Please select the appropriate response from the drop down menu. 1. None of the Time 2. A little of the Time 3. Some of the Time 4. Most of the Time 5. All of the Time Calculation of answers Total: Comments / Questions Your feedback is important to us as it allows us to provide the best quality care and service for you the client. Please take a moment to fill in the following survey. * YesNo CLIENT FEEDBACK After reading each comment below, please indicate your answer by selecting the response that best describes your experience. Date * Psychologists Name * First Name Last Name Client's Name 1. My therapist was warm, friendly and accepting. * Strongly Agree Agree Disagree Strongly Disagree 2. I felt that my therapist had the skills to help me achieve my goals. * Strongly Agree Agree Disagree Strongly Disagree 3. The admin staff was efficient and helpful in processing payments an scheduling appointments. * Strongly Agree Agree Disagree Strongly Disagree 4. I found the admin staff warm and friendly. * Strongly Agree Agree Disagree Strongly Disagree If you disagreed please elaborate: 5. Overall, I feel that I have been making: * Significant Progress Considerable Progress Some Progress No Progress 6. Please indicate which aspects of your experience were most helpful. 7. Were there any aspects of your experience that did not meet your expectations? Would you like a follow up email or phone call from Redlands Psychologists in regards to your experience with us? Select if you wish for follow up contact: Yes No Thank you for taking the time to complete the questionnaires. recaptcha
