Therapy Update

Therapy Visit Form

Name(Required)
Date of Birth(Required)
What type of visit is this for?
This form will go directly to the person you select.

Over the past week, rate your...

None = 0
A little = 1, 2
Medium = 3,4
A lot = 5,6

Psychological

Overall sense of well-being
I take on things that are challenging or difficult
I do things that are engaging, meaningful, or in-line with my values and goals (eg social, spiritual, family, career, hobbies, creative, athletic, etc)
I've had thoughts that are hard to talk about in therapy (eg suicide, self-harm, addiction, trauma, shame, etc)
Other

Physical

Brisk walking or exercise
Outdoor activity
Healthy food (fish, fruit, veggies, whole grains, nuts, beans)
Use of alcohol or recreational drugs
Other

Sleep

I get out of bed at a regular time
During the day, I stay out of bed and don't nap
I reserve a time to wind-down before bed
I don't try to force sleep. I only go to bed when tired
Other

Therapy

My overall satisfaction with therapy
My therapist's approach is a good fit for me
I apply what I've learned in therapy to my life
I take my psychiatric or other meds as prescribed
Other