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PATIENT PORTAL
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Therapy Update
Therapy Visit Form
Name
(Required)
First
Last
Date of Birth
(Required)
Month
Day
Year
What type of visit is this for?
Telemedicine eVisit
Phone Consultation
Other
Therapist
This form will go directly to the person you select.
--Please Select--
Kyndal Auten
Ben Bentley
Susan Blevins
Kaitlyn Boone
Nick Boulet
Marianna Bowen
Ginny Brookshire
Alex Chauvin
Courtney Deakle
Elena Dolman
Suzanne Doyle
Patti Eaves
Nancy Foster
Sara Freeman
Alexandra Fuentes-Whitman
Tonia Glasco
Cheryl Goldberg
Josh Gutierrez
Justin Haber
Kalyn Hamilton
Cam Hines
Don Holland
Callie Hutchens
Laura Ingalls
Randy Johnson
Wanda Kellyman
Danielle Kim
Brian Kreher
Sarah Lempka
Brianna Lowery
Greg Moore
Lynda Noffsinger
Kristen Pascal
Jessica Phipps
Lindsay Ponce
Jeff Rinehart
Monica Robinson
Jillie Rogers
Matt Ross
TJ Shaffer
Sheila Shelton-Whisenant
Caitlin Smith
Tina Spach
Becky Stevens
Esther Suess
Alyssa Triolo
Ann Marie Tucker
Ali Turner
Beth Wagner
Kayt Warren
Leah Wolff
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
N/A
0
1
2
3
4
5
6
I take on things that are challenging or difficult
N/A
0
1
2
3
4
5
6
I do things that are engaging, meaningful, or in-line with my values and goals (eg social, spiritual, family, career, hobbies, creative, athletic, etc)
N/A
0
1
2
3
4
5
6
I've had thoughts that are hard to talk about in therapy (eg suicide, self-harm, addiction, trauma, shame, etc)
N/A
0
1
2
3
4
5
6
Other
N/A
0
1
2
3
4
5
6
Physical
Brisk walking or exercise
N/A
0
1
2
3
4
5
6
Outdoor activity
N/A
0
1
2
3
4
5
6
Healthy food (fish, fruit, veggies, whole grains, nuts, beans)
N/A
0
1
2
3
4
5
6
Use of alcohol or recreational drugs
N/A
0
1
2
3
4
5
6
Other
N/A
0
1
2
3
4
5
6
Sleep
I get out of bed at a regular time
N/A
0
1
2
3
4
5
6
During the day, I stay out of bed and don't nap
N/A
0
1
2
3
4
5
6
I reserve a time to wind-down before bed
N/A
0
1
2
3
4
5
6
I don't try to force sleep. I only go to bed when tired
N/A
0
1
2
3
4
5
6
Other
N/A
0
1
2
3
4
5
6
Therapy
My overall satisfaction with therapy
N/A
0
1
2
3
4
5
6
My therapist's approach is a good fit for me
N/A
0
1
2
3
4
5
6
I apply what I've learned in therapy to my life
N/A
0
1
2
3
4
5
6
I take my psychiatric or other meds as prescribed
N/A
0
1
2
3
4
5
6
Other
N/A
0
1
2
3
4
5
6
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