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Session Check-In Form
Donny Baca, MA, LPC
Please correct the errors described below.
Initials Only:
Today's Date:
Primary Complaint
Homework Completed:
None Given
Yes
No
Select One
Since my last office visit my symptoms have:
Much Worse
More Severe
No Change
Less Severe
Much Improved
Resolved/Absent
Select One
Please describe your symptoms/concerns/complaint experienced (be specific):
What coping strategies did you use that helped decrease your symptoms?
None
Therapy Sessions
Breathing Exercises
Mindfulness Exercises
Physical Exercise
My Support Network
Meditation Exercises
Journaling
Self-Care
Other
Using the scale below, rate your symptoms between 0 to 10 with 10 being the most severe symptoms.
0 (No Symptoms)
2
3 (Mild Symptoms)
4
5
6 (Moderate Symptoms)))))
7
8
9
10 (Severe Symptoms)
Select One
I have experienced these symptoms:
Not at all
1 - 3 days out of 7 days
More than half the days of the week
Nearly every day
Select One
The symptoms I experienced lasted approximately:
Not at all
0 - 60 Minutes
1 - 5 Hours
Most of the day
The whole day
Select One
How would you describe your sleeping habits?
Normal
Trouble falling asleep
Trouble remaining asleep through the night
Waking up too early
Not feeling rested after an adequate night of sleep
Select One
How would you describe your appetite?
Normal
Decreased
Increased
Restricted
Binging and/or purging
Select One
Are you currently having thoughts of killing yourself?
-Select One-
Yes
No
Are you currently engaged in self-harm?
-Select One-
Yes
No
If yes, please describe:
Are you currently contemplating harming another person?
-Select One-
Yes
No
If yes, please describe:
Are you currently taking your medications as prescribed?
-Select One-
Yes
No
N/A
Is there anything specific you would like me to talk with you about today?
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