Therapy Documentation Form 2 – First Session Therapy Documentation Form – Confidential )Progress Note and Report) Your Name * Client’s Unique Code * Session * First Session Was the client private? * Yes No Date of Session * Time of Session * Duration of Session * Presenting Complaints * History of Presenting Complaints * Substance Use History * Yes No If Yes, Please Provide List of Substance, Quantity and Frequency Past Psychiatric History * Yes No If yes, please describe Suicidal Ideation * Yes No If yes, please provide details. Please include details of previous attempt if applicable Homicidal Ideation * Yes No If yes, please describe Hallucinations * Yes No Could Not Access Please Describe. If you did not access, give reasons why Delusions * Yes No Could Not Access Please Describe. If you did not access, give reasons why Observable Behaviours * Any Psychometric Tests Administered? * Yes No If Yes, Provide Details of the Psychometric Test (including test name and scores) Please include the name of the test, test scores, etc. If Yes, Provide Details of the Test Taking Behavior Did you conduct a MSE? * Yes No If Yes or No, Please Provide Reasons and More Details. * Is the client seeing another professional? (e.g. a Psychiatrist) * Yes No Does the client have a previous therapy experience? * Yes No What Are The Clients Strengths and Support? * Your Working Hypothesis (Case Formulation) * Treatment Goals (SMART) – In Order of Priority * How Did You Prioritize Goals? * What is the Treatment Intervention(s) (e.g. CBT, ACT) * What Is Your Rationale For Choosing Treatment Intervention(s)? * Current Intervention Activity. (What Intervention activity was done at this session?) * What is Client’s Sense of Satisfaction With Your Service? * How Did You Access Clients Sense of Satisfaction With Your Service? * Any Challenges With The Session * Your Comments (A detailed report for this session) * What Home Work Did You Give Client? * Working Diagnosis * Depression Anxiety Relationship Challenges OCD Work Stress and Burnout Trauma Related Challenges (e.g. PTSD) Personality Disorder Bipolar Affective Disorder Eating Disorder Schizophrenia Others Next Session Plan * Any Additional Information If you are human, leave this field blank. Submit Δ
