Session Check-In Form

Initials Only:

Today's Date:

Assigned Therapist

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

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

What has changed for the BETTER since your last session?

Did anything change for the WORSE?

Please answer the following four questions:

Since my last office visit my symptoms have been:

The symptoms were present:

The symptoms I experienced lasted approximately:

Using the scale below, rate the severity of your symptoms between 0 to 10 with 10 being the most severe symptoms.

0=No Symptoms 3=Mild Symptoms 6= Moderate Symptoms 10=Severe Symptoms

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

None

Counseling Sessions

Breathing Exercises

Mindfulness Exercises

Self-Care

Support Network

Meditation Exercises

Journaling

Container

Physical Exercise

Safe/Calm Place

Healthy Nutrition

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?

Is there anything you would like me know that was not asked on this form?