General Feedback

How would you rate your overall experience with Makin Wellness? *

• Excellent
• Good
• Fair
• Poor

What aspects of our services did you find most helpful? *

• Counseling/therapy sessions
• Online resources
• Therapist support
• Scheduling flexibility
• Client care support
• Other (please specify)

If other

What aspects of our services did you find most helpful? (copy) *

• Counseling/therapy sessions
• Scheduling conflicts
• Financial concerns
• Personal circumstances
• Lack of progress
• Other (please specify)

If other

Reasons for Discontinuation

Why did you decide to discontinue therapy at this time? *

• I feel I no longer need therapy
• I had a scheduling conflict
• I found another therapist
• I didn’t feel a connection with my therapist
• Online is not working for me
• Technical issues
• Financial concerns
• Other (please specify):

If other

What could we have done differently to keep you engaged in therapy? *

Referrals

Do you know anyone who could benefit from our services?YesNo

If yes, would you be willing to share their contact information with us?

Name

First

Last

Email

Phone

Would you like to receive any updates or resources from us in the future? *YesNo

Please share any additional comments or suggestions you have for us:

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