Client Check in

Client Check-in Form
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your therapist
Your Name

First NameLast Name
Client Initials
Your Email Address
example@example.com
Client Report: since your last session, what are specific activities you have done to help yourself meet your goals?

Check-in - indicate 0 - 10 (0 = low amount, 10 = high amount)

Tobacco Use
Alcohol use per week:
Have you had a fall since your last visit:
Are you experiencing physical pain?
If yes, what is your pain level? (0 = low, 10 = high)
If yes, where does your body hurt?
Are you taking your medications as prescribed?
If no, please explain
Have your Medications/Vitamins/Supplements changed?
If yes, please provide the name of new medication, dosage, why it was prescribed, and the name of the prescribing physician.
Do you feel safe at home?
If no, please explain.
Area(s) I want to focus on today
Should be Empty:

Client Check-in Form