Client Name
*
Date of Session
-
Year
-
Month
Day
Date
Time of Session
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Session Number:
*
Session Type
*
Solo
Couple
Family
Dog and Cat
Affect:
Appropriate
Blunted
Constricted
Flat
Labile
Appearance:
Well Groomed
DIsheveled
Inappropriate
Attitude:
Cooperative
Guarded
Uncooperative
Mood:
Euthymic
Depressed
Anxious
Euphoric
Mood Activity:
Calm
Hyperactive
Agitated
Tremors / Tics
Orientation:
Fully Oriented
Disoriented as to Time
Disoriented as to Place
Disoriented as to Person
North
South
East
West
Thought Process:
Intact
Circumstantial
Tangential
Loosening Assoc
Thought Content:
Appropriate
Hallucinations
Delusions
Speech:
Option 1
Option 2
Option 3
Interview Behaviour:
Option 1
Option 2
Option 3
Associations:
Option 1
Option 2
Option 3
Insight / Judgement:
Option 1
Option 2
Option 3
Relational Assessment
Good
Fair
Poor
Communication
1
2
3
Intimacy
4
5
6
Overall Progress
Low
Medium
High
Distress Level
7
8
9
Focus of Session
Goals
Good
Fair
Poor
Progression Towards Goals
10
11
12
Plan
Submit
Should be Empty: