Therapy Client Weekly Emotional Check-in
Please complete this form to reflect on your emotional well-being and share your experiences from the past week.
Full Name
*
First Name
Last Name
Date of Check-in
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How would you rate your overall emotional well-being this week?
*
1
2
3
4
5
Which emotions have you experienced most strongly this week? (Select all that apply)
*
Happiness
Sadness
Anxiety
Anger
Calm
Loneliness
Hopefulness
Other
Please describe any significant events or challenges you faced this week.
*
How well did you cope with stress this week?
*
Not at all
1
2
3
4
Very well
5
1 is Not at all, 5 is Very well
What coping strategies did you use this week? (Select all that apply)
Talking with friends/family
Physical activity/exercise
Mindfulness/meditation
Journaling
Creative activities (art, music, etc.)
Professional support (therapy, counseling)
Other
What went well for you this week?
What was most difficult for you this week?
What support do you feel you need right now? (Select all that apply)
More time for self-care
Emotional support from others
Professional guidance
Stress management techniques
Other
What is one goal you have for yourself in the upcoming week?
Is there anything else you would like your therapist to know this week?
Submit Check-in
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