Therapy Documentation Form - 360 Psyche (Confidential)

Therapy Documentation Form - Confidential )Progress Note and Report)

Therapy Documentation Form - Confidential )Progress Note and Report)

This form documents your therapy activities. Consider it a hospital file for patient's documentation, kindly make it as detailed as possible. The purpose of documentation is for future references, and to avoid any challenges that may arise in future. The form is required to be completed for each scheduled session. If for some reasons a scheduled appointment does not hold, please complete the form still and indicate this, then put N/A on other areas Thank you for your time. #Note: SMART - Simple, Measurable, Attainable, Realistic, and Time-Bound

Did the session hold?
Was the client private?
Substance Use History
Past Psychiatric History
Suicidal Ideation
Homicidal Ideation
Hallucinations
Delusions
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?
Has the Goals Changed?