Coping Exercise Log Form
Use this form to record details about a coping exercise you practiced, including what prompted it, how you felt, and your reflections.
Date and time you practiced the coping exercise
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
What triggered you to use a coping exercise?
*
Which coping technique did you use?
*
Please Select
Deep breathing
Mindfulness
Journaling
Physical activity
Talking to someone
Creative activity
Other
Describe the coping exercise you practiced
*
How long did you practice the coping exercise? (in minutes)
*
How did you feel before starting the exercise?
*
Very stressed
1
2
3
4
Very calm
5
1 is Very stressed, 5 is Very calm
How did you feel after completing the exercise?
*
Very stressed
1
2
3
4
Very calm
5
1 is Very stressed, 5 is Very calm
How effective did the exercise feel for you?
*
1
2
3
4
5
Any notes or reflections?
Would you like a follow-up reminder for this exercise?
*
Yes
No
Submit Log
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