Dr. James Shafer's Evaluation

Dr. James T. Shafer

Specialty:: child, adolescent, adult therapy

I'm Dr. Jim Shafer, and I welcome you to my psychological practice. I provide counseling to adults, married couples and single individuals. I also provide testing when it is appropriate.

Life is difficult. Together we find strategies to better cope with life's challenges. My approach is a combination of cognitive behavioral therapy, guided imagery, and, supportive therapy.

Patient Evaluation Form

Please use this form to submit an evaluation of your previous visit with Dr. Shafer. All submitted information is kept entirely confidential. No Information from this evaluation is sent to anyone other than Dr. Shafer.

Personal Information

You may submit this evaluation anonymously by leaving the following fields regarding your personal information blank.

Last Name:

First Name:

Date of Last Visit: / /

Questionnaire

You may choose to leave any field blank that you do not wish to answer.

13. Please explain any low ratings. What did you like least about the treatment?

14. Did you have any problems that you were not able to discuss in the therapy? Were there issues or feelings you felt your therapist did not understand?

15. Was there anything that your therapist said during the therapy that irritated you or rubbed you the wrong way? What did you like least about the therapist?

16. Please explain any high ratings on the scale above. What was the most helpful and useful part of the therapy for you?

17. What did you like the best about your therapist?

18. What were the most helpful ideas or techniques that were discussed? Will you be using any specific skills or ideas to deal with personal problems or mood swings in the future?

19. Were you comfortable with your therapist's orientation (school of therapy) and with the methods and techniques she or he used?

20. Were you satisfied with your therapist's warmth and genuineness?

Please choose the option which most accurately describes your feelings.	Not at all	Somewhat	Moderately	A lot	Does not apply
1. The therapy was helpful to me.
2. I was able to talk about my problems and get some of my feelings off my chest.
3. The therapy helped me understand more about myself.
4. The therapy helped me change some of my negative thoughts and self-defeating attitudes.
5. I learned to communicate more effectively and improve my relationships with people.
6. I learned techniques to improve my productivity or to function more effectively in my daily activities.
7. I learned to solve problems in my career or personal life.
8. The self-help assignments between sessions were useful.
9. I was able to develop better control of bad habits such as overeating or abusing drugs or alcohol.
10. How satisfied do you feel with the therapy overall?

Please answer these questions on the self-help assignments.	Almost Never	0-1 days per week	2-3 days per week	4-5 days per week	6-7 days per week
11. How often did you do self-help assignments, on the average?
12. How often did you do self-help activities that were not assigned?

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Dr. James T. Shafer

Patient Evaluation Form

Personal Information

Questionnaire