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Exit Survey

Thank you for choosing Patchwork Therapy. Our goal is to provide clients with a positive experience and to ensure they feel supported throughout their care. As part of that commitment, we’d appreciate your feedback on your time with us. The questions below will help us understand what worked well and where we can improve for future clients. You are welcome to leave your name blank if you’d prefer to remain anonymous.

Your Therapist's Name (Optional)
Please rate your sessions with your therapist:
1 - I did not feel heard, understood, or respected.
2
3 - Somewhat
4
5 - I felt heard, understood, and respected.
Goals and Topics in your sessions:
1 - We did not work on or talk about what I wanted to work on or talk about.
2
3 - Somewhat
4
5 - We worked on and talked about what I wanted to work on and talk about.
Your therapist's approach or method:
1 - My therapist's approach was not a good fit for me.
2
3 - Somewhat
4
5 - My therapist's approach was a good fit for me.
Overall:
1 - Overall there was something missing in the session.
2
3 - Somewhat
4
5 - Overall our session was right for me.

How you are feeling:

Thinking back on your sessions, please rate how you (or the person you’re completing this for) have been doing in each of the following areas of life. Marks toward the top (1) indicate lower levels, while marks toward the bottom (5) indicate higher levels.

Individually (personal well-being)
1
2
3
4
5
Interpersonally (family, close relationships)
1
2
3
4
5
Socially (school, work, friendships)
1
2
3
4
5
Overall (general sense of well-being)
1
2
3
4
5

Your experience with administrative staff:

Please share your experience with our scheduling and billing processes.

How was your experience with scheduling an appointment at Patchwork Therapy?
1 - It was difficult to get in touch with and schedule an appointment with a therapist.
2
3 - Somewhat
4
5 - It was easy to get in touch with and schedule an appointment with a therapist.
How was your experience with our billing department?
1 - I did not have a good experience with the billing department.
2
3 - Fair
4
5 - I had a good experience with the billing department.
How satisfied were you with the office facility (e.g., comfort, cleanliness, accessibility)
1 - Very Dissatisfied
2
3 - Somewhat
4
5 - Very Satisfied

© 2026 Patchwork Therapy PLLC

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