| Gender Identity (Optional): |
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| Race (Optional): |
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| Please select the choice that best describes your agreement with the following statements: |
| I was able to set up an appointment within a reasonable time: |
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| The reception staff was friendly and helpful: |
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| I am confident that the Counseling and Wellness Center keeps my information confidential: |
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| The Counseling and Wellness Center is a warm and welcoming environment: |
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| I would recommend the Counseling and Wellness Center to a friend: |
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| I cope better with the problems that brought me to counseling: |
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| My counselor created a supportive and open environment: |
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| Counseling has helped me remain in school: |
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| If needed, I will use the Counseling and Wellness Center in the future: |
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| What did you find most helpful about counseling? |
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| If you are no longer receiving services, what was the primary reason for leaving? |
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| Do you have any suggestions for improvement? |
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| Overall, I am satisfied with the services received: |
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| Your Counselor's Name: |
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| Please provide any additional feedback or comments you may have. |
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