Session Check-In Form

Initials Only:

Today's Date:

Primary Complaint

Therapeutic Enrichment Exercise(s) Completed:

Since my last office visit my symptoms have been:

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.

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

I have experienced these symptoms:

The symptoms I experienced lasted approximately:

How would you describe your sleeping habits?

How would you describe your appetite?

Are you currently having thoughts of killing yourself?

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 specific you would like me to talk with you about today?

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