Session Feedback Form | NeuroPlay Therapy

First name

Last name

Phone

Are you completing this form right afte the sesson?

Yes

Session Date & Time

Current Date & Time

What are you feeling at the conclusion of this session? What are the reasons behind these emotions?

What percent of what you sharedtoday do you feel I understood correctly, and what could I have understood better?

Did you have any realizations during this session?

What will you try to remember this week? What is your goal for this week?

Do you think that today's session helped you get closer to your goals? Describe how it did or didn't do so:

Is there anything you wanted to bring up, but didn't get around to?

Is there anything you want me to remind you to bring up next week?

At any point during the session, did you feel like I was taking the conversation in a different direction than you wanted?

Yes

Describe what it was, and let me know if it was:

Did you feel that it made the session less beneficial in some way? More beneficial in some way? Please describe:

Enter any tasks we planned for this week:

On a scale of 1-100%, how confident are you that this task will help you reach your goal in the timeline you want?

Enter any tasks we planned for this week:

Timeline confidence for task 2

Enter any tasks we planned for this week:

Timeline confidence for task 3

On a scale of 1-100%, how motivated are you to do this task?

Motivation for task 2

Motivation for task 3