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Feedback Form
Feedback Form
Cycle Closing Questionnaire
Please answer all the questions as completely and as honestly as you can. Include both positive and negative feedback.
Name (or leave blank if you prefer anonymity)
Date
Group
(Required)
1. What about participating in group has been most beneficial for you?
2. What has been most difficult for you to accept?
3. Why have you continued (or not continued) with the group?
4. What would you personally like to get out of group?
5. Tell me anything else you feel I should know.
6. Are you planning to return next cycle?
Yes, I am.
No, I’m not.
I’m unsure.
It depends.
7. If you checked anything other than "Yes, I am.," and would like to say more about your reasons, please do so below.
8. Please check all times you are available next cycle. Try to be as generous as possible with your choices.
Tuesdays at 10
Tuesdays at 11
Wednesdays at 10
Wednesdays at 11
Thursdays at 10
Thursdays at 11
Disclaimer – Sessions with Dr. Spitz are group therapy sessions. Any session in which Dr. Spitz is not present is a PEER to PEER counseling session only.
I have read, understood and agree to the above disclaimer.
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