Session Check-In Form

Initials Only:

Today's Date:

Assigned Therapist

Primary Complaint (e.g. Depression, ADHD, Anxiety, PTSD)

Please answer the following four questions. (Circle to indicate your answer)

1. How much has the problem for which you sought treatment been resolved?

2. Rate any changes in how well you are doing in your job since you started treatment.

3. Rate any changes in how well you are doing in your marital/family relationships since you started treatment.

4. Rate any changes in your general happiness & well-being since you started treatment.

Please describe your symptoms/concerns/complaint experienced (be specific e.g. feeling down, depressed, or hopeless, feeling nervous, anxious, on edge):

I have experienced these symptoms:

The symptoms I experienced lasted approximately:

What coping strategies did you use that helped decrease or manage your symptoms?

None

Counseling Sessions

Breathing Exercises

Mindfulness Exercises

Checkbox

Support Network

Meditation Exercises

Journaling

Self-Care

Other coping strategy used:

How would you describe your sleeping habits?

How would you describe your appetite?

Are you currently having thoughts of killing yourself?

If yes, please describe:

Are you currently engaged in self-harm?

If yes, please describe:

Are you currently contemplating harming another person?

If yes, please describe:

Are you currently taking your medications as prescribed?

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