Toggle navigation
Session Check-In Form
Donny Baca, MA, LPC
Please correct the errors described below.
Initials Only:
Today's Date:
Primary Complaint
Therapeutic Enrichment Exercise(s) Completed:
-Select One-
None Given
Yes
No
Since my last office visit my symptoms have been:
-Select One-
Much Worse
More Severe
No Change
Less Severe
Much Improved
Resolved/Absent
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 coping strategy used:
Using the scale below, rate your symptoms between 0 to 10 with 10 being the most severe symptoms.
-Select One-
0 (No Symptoms)
2
3 (Mild Symptoms)
4
5
6 (Moderate Symptoms)
7
8
9
10 (Severe Symptoms)
0=No Symptoms 3=Mild Symptoms 6= Moderate Symptoms 10=Severe Symptoms
I have experienced these symptoms:
-Select One-
Not present
My symptoms were present but minimal
1 - 3 days out of 7 days
More than half the days of the week
Nearly every day
The symptoms I experienced lasted approximately:
-Select One-
Not at all
The symptoms were present but minimal
0 - 59 Minutes
1 - 5 Hours
Most of the day
The whole day
How would you describe your sleeping habits?
-Select One-
Normal
Trouble falling asleep
Trouble remaining asleep through the night
Waking up too early
Not feeling rested after an adequate night of sleep
How would you describe your appetite?
-Select One-
Normal
Decreased
Increased
Restricted
Binging and/or purging
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-
N/A
Yes
No
Is there anything specific you would like me to talk with you about today?
Your message will be encrypted.
Hide