Therapy Update

Please complete this before your therapy appointment. We will track your answers and - over time - that information forms patterns that will help us optimize your treatment plan.

What type of visit is this for?

Telemedicine eVisit

Phone Consultation

Other

Name(Required)

First Last

Date of Birth(Required)

Phone(Required)

Best time to reach you

If you already have an appointment scheduled, you do not have to answer this question.

Email(Required)

Therapist

This form will go directly to the person you select.

Is this visit already scheduled?

Yes

No

Unsure

Appointment Date

Reason for Consult

Tell me the problem you'd like help with

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

First Choice

Second Choice

Third Choice

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

Anything else you'd like me to know?

Today's Date

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Therapy Visit Form