Therapy Visit Form

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


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)


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


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


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