Reality Therapy Evaluation Form
Please complete this form to assist in evaluating the application of reality therapy principles during the session.
Client Full Name
*
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Evaluator Name
*
First Name
Last Name
Client's Age
*
Please indicate the extent to which the client demonstrates the following reality therapy concepts:
*
Rows
Not at all
Rarely
Sometimes
Often
Always
Takes responsibility for own actions
1
2
3
4
5
Focuses on present behavior
6
7
8
9
10
Identifies wants and needs clearly
11
12
13
14
15
Engages in planning for change
16
17
18
19
20
Accepts consequences of choices
21
22
23
24
25
How would you rate the client's understanding of the core needs (Love/Belonging, Power, Freedom, Fun, Survival)?
*
1
2
3
4
5
What is the client's level of engagement in the session?
*
Very Low
Low
Moderate
High
Very High
Does the client demonstrate a willingness to make effective plans for change?
*
Yes
Somewhat
No
Please provide any observations regarding the client's strengths in applying reality therapy principles.
Recommendations or next steps for the client (if any):
Evaluator's Signature
*
Submit Evaluation
Submit Evaluation
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