*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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