Your birthday and the last four digits of your Social Security Number are needed for us to identify your data while keeping it anonymous to others.
Social Security Number (last four digits only)
Name of therapist (primary therapist) at

INSTRUCTIONS: Below is a list of statements about your relationship with your therapist. Consider each item carefully and indicate your level of agreement for each of the following items. Please write down the rating scale because it makes it easier to answer items.

    1 = Does not Correspond at all
    3 = Corresponds Moderately
    5 = Corresponds Exactly

 1  2  3  4  5
My therapist and I agree about the things I will need to do in therapy to help improve my situation.
What I am doing in therapy gives me new ways of looking at my problem.
I believe my therapist likes me.
My therapist does not understand what I am trying to accomplish in therapy.
I am confident in my therapist's ability to help me.
My therapist and I are working towards mutually agreed upon goals.
I feel that my therapist appreciates me.
We agree on what is important for me to work on.
My therapist and I trust one another.
My therapist and I have different ideas on what my problems are.
We have established a good understanding of the kind of changes that would be good for me.
I believe the way we are working with my problem is correct.

Since the last time you filled this out (or since starting therapy, if this is the first time):

Please describe anything else about therapy that has been particularly helpful

Please describe anything else about therapy that needs to improve