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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
Susan Blevins
Patricia Blum
Nick Boulet
Ginny Brookshire
Suzanne Doyle
Nancy Foster
Alexandra Fuentes-Whitman
Antonia Glasco
Cheryl Goldberg
Justin Haber
Kalyn Hamilton
Callie Hutchens
Don Holland
Tess Job
Danielle Kim
Brian Kreher
Randy Johnson
Brianna Lowery
Greg Moore
Lynda Noffsinger
Jeff Rinehart
Lina Roe
Jillie Rogers
Matt Ross
TJ Shaffer
Sheila Shelton-Whisenant
Becky Stevens
Laura Strickland
Alyssa Triolo
Ann Marie Tucker
Ali Turner
Esther Whyte
Leah Wolff-Pomfrey
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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