Youth Individual Counseling Outcome Questionnaire

Name *

First

Last

Zip Code *

Date / Time *

Date

Time

Assigned therapist *

1=Strongly disagree 2=Disagree 3=Neutral 4=Agree 5=Strongly agree

I know about the different feelings of grief.

Selected Value: 0

I have talked about the person who died.

Selected Value: 0

I understand that everybody grieves differently.

Selected Value: 0

I express my feelings to others.

Selected Value: 0

I can name coping skills that work for me.

Selected Value: 0

I am hopeful for the future.

Selected Value: 0

My therapist helped me feel understood.

Selected Value: 0

I am glad I came to grief counseling.

Selected Value: 0