Compliance Therapy Assessment
Please complete this assessment to help evaluate therapy adherence and address any challenges with the treatment plan.
Client Full Name
*
First Name
Last Name
Date of Assessment
*
-
Month
-
Day
Year
Date
Therapist Name
*
First Name
Last Name
Contact Email
*
example@example.com
How well do you understand your current treatment goals?
*
Not at all
1
2
3
4
Completely
5
1 is Not at all, 5 is Completely
Please rate your engagement with therapy activities since your last session.
*
1
2
3
4
5
In the past week, how often did you complete your assigned therapy tasks?
*
Always
Most of the time
Sometimes
Rarely
Never
Please indicate the extent to which the following factors have impacted your therapy compliance.
*
Rows
Not at all
Slightly
Moderately
Significantly
Extremely
Lack of motivation
1
2
3
4
5
Time constraints
6
7
8
9
10
Emotional distress
11
12
13
14
15
Forgetfulness
16
17
18
19
20
Unclear instructions
21
22
23
24
25
Other
26
27
28
29
30
What barriers, if any, have prevented you from fully participating in therapy? (Select all that apply)
Work or school commitments
Family obligations
Transportation issues
Financial concerns
Lack of support
Other
Please share any additional comments or concerns regarding your therapy participation.
Signature (Please sign to confirm your responses)
*
Submit Assessment
Submit Assessment
Should be Empty: