Therapy Update

Therapy Visit Form

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?
Name(Required)
Date of Birth(Required)
If you already have an appointment scheduled, you do not have to answer this question.
This form will go directly to the person you select.
Is this visit already scheduled?
Appointment Date
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
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
Today's Date