*Therapist

*Client's Name
Client's age

*Therapy

Location

Language

Type

Gender of Client

*Date of first session (YYYY-MM-DD)
*Date of last session (YYYY-MM-DD)

*Total number of sessions
*Fee per session

*Do you feel the client's goals were met?
(1 = Not at all; 3 = Some Goals; 5 = Most Goals)

*Timing of Termination
(1 = Sudden; 3 = Premature; 5 = Appropriate)

*How satisfied were you with the outcome of the case?
(1 = Very Unsatisfied; 3 = Satisfied; 5 = Very Satisfied)

Additional Comments

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