Counselling Feedback Thankyou for your attendance at a Converge International counselling session, we trust that this was a positive and helpful experience for you. We are committed to providing services of the highest quality. We would greatly appreciate if you would take just a couple of minutes to complete this short questionnaire about your experience with Converge International. Your responses will be kept completely confidential and you may decline to answer any particular questions if you wish. You will not be asked to give your name in this questionnaire.

Please indicate the degree to which you agree or disagree with the following statements:

Strongly Disagree Neutral Strongly Agree The person who received my initial contact was professional and compassionate My appointment was at a convenient time and date My appointment was at a convenient location My counsellor understood the issues I discussed My counsellor was a good listener Counselling was helpful for me I would recommend Converge International to a colleage Overall, I was satisfied with my experience with Converge International

Any additional comments:

Please check if you do not give permission for your comments to be used in promotional material.

Below are a few short questions about yourself and your counselling session. Your answers will be treated in the strictest confidence.

How did you find out about Converge International?

- Select One - 1. Colleague 2. Manager/HR 3. Brochure/poster 4. Friend/family 5. Other

How soon after your initial contact was your session?

- Select One - 1. Less than 2 days 2. 2-7 days 3. 8-13 days 4. More than 2 weeks

Employer Company

Counsellor Name

Session #

- Select One - 1 2 3 4 5 6 7 8 9 10+

Date of session

Gender

- Select One - 1. Female 2. Male

State

- Select One - 1. ACT 2. NSW 3. NT 4. Qld 5. SA 6. Tas 7. Vic 8. WA

Age	- Select One - 1. Less than 25 2. 25-34 3. 35-44 4. 45-54 5. 55-64 6. 65+

Length of employment

- Select One - 1. Less than one year 2. 1-2 years 3. 3-5 years 4. 6-10 years 5. 10-20 years 6. More than 20 years