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Our Model
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Match With a Counselor
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Client Feedback
Name
(Required)
First
Last
Email Address
(Required)
How did you hear about MyCounselor.Online?
(Required)
Someone I trust recommended you.
I found you online.
I saw / heard your advertisement.
Please Specify
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If you Google searched, what did you search for?
If you followed a link from another site, what was the site?
If a billboard, where at?
If a flyer or brochure, on what topic?
Your Age
(Required)
Your Gender
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Your Ethnicity
(Required)
Marital Status
(Required)
Single
Engaged
Married
Separated
Divorced
Type of Counseling
(Required)
Individual Counseling
Marriage Counseling
Sex Therapy
Family Therapy
Household Income (Optional)
Less than $25,000
$26,000 - $50,000
$51,000 - $100,000
More than $100,000
Where do you live?
(Required)
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
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Bosnia and Herzegovina
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Bouvet Island
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Chile
China
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Congo, Democratic Republic of the
Cook Islands
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Croatia
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Djibouti
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Dominican Republic
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El Salvador
Equatorial Guinea
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Ethiopia
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French Southern Territories
Gabon
Gambia
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Indonesia
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Iraq
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Korea, Republic of
Kuwait
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Libya
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Mali
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Mayotte
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Nigeria
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Panama
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Poland
Portugal
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Russian Federation
Rwanda
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Thailand
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US Minor Outlying Islands
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Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Based on your experience so far, how likely are you to recommend MyCounselor.Online to someone you love?
(Required)
Definitely Will
Not Sure
Unlikely
Intake Call
Please rate your experience with the intake call process, with 3 being "Yes", 2 being "Somewhat", and 1 being "No, not really".
Booking an initial intake call with the receptionist was an easy and pleasant experience.
(Required)
3
2
1
The receptionist was on time for the intake call.
(Required)
3
2
1
The receptionist was pleasant, kind, and helpful during the intake call.
(Required)
3
2
1
The receptionist clearly answered all of my questions and properly explained the process during the intake call.
(Required)
3
2
1
The website was easy to navigate.
(Required)
3
2
1
I was able to locate all intake paperwork on the website.
(Required)
3
2
1
Did the receptionist explain our cancellation policy?
(Required)
Yes
No
Counseling Session
Please rate your experience with your counseling session, with 3 being "Yes", 2 being "Somewhat", and 1 being "No, not really".
My counselor was warm, accepting, supportive, and engaged at my first session.
(Required)
3
2
1
My counselor created a safe place for me to share.
(Required)
3
2
1
My counselor was on time for my first session.
(Required)
3
2
1
My time with my therapist felt productive.
(Required)
3
2
1
I felt like my therapist understood me and the challenges that I am facing.
(Required)
3
2
1
Which counselor did you meet with?
(Required)
Are you ok with us sharing your feedback with your counselor?
(Required)
Yes
No
May we call you for additional information on your experience?
(Required)
Yes
No
Phone
(Required)
Please share any comments, concerns or suggestions we can consider in providing the best care for our clients.
