Therapy Documentation Form 2 – First Session

Therapy Documentation Form – Confidential )Progress Note and Report)
Was the client private?
Substance Use History
Past Psychiatric History
Suicidal Ideation
Homicidal Ideation
Any Psychometric Tests Administered?
Please include the name of the test, test scores, etc.
Did you conduct a MSE?
Is the client seeing another professional? (e.g. a Psychiatrist)
Does the client have a previous therapy experience?