Client Check-in Form
Date
*
/
Month
/
Day
Year
Date
Your therapist
*
Please Select
Dr. Curtis Beeman
Dr. Anna Ciampanelli
Dr. Pat Francis, O.P.
Ashley Kranz, LCSW
Dr. Ann Letourneau
Dr. Elissa McGovern
JoAnne McKee, LCPC
Colleen Narbone, LPC
Kristen Ras, LCPC
Linda Schumacher, LPC
Derrick Smith, MS, MA
Chris Stuart, LPC
Susan Crickmore Williams, LCPC
Rihab Yako, LCSW
Matthew McRay, BA
Conrad Painley, MA
Francisco Villate, MA
Dr. Test
Your Name
*
First Name
Last Name
Client Initials
*
Your Email Address
*
example@example.com
Client Report: since your last session, what are specific activities you have done to help yourself meet your goals?
*
Check-in - indicate 0 - 10 (0 = low amount, 10 = high amount)
*
Rows
Amount
Depressed
Violent towards self
Sleep
Nutrition
Anxious
Violent towards others
Exercise
Happy
Relationship Satisfaction
Angry
Tobacco Use
*
Yes
No
Alcohol use per week:
0 - 2
3 - 5
5+
Have you had a fall since your last visit:
*
Yes
No
Are you experiencing physical pain?
*
Yes
No
If yes, what is your pain level? (0 = low, 10 = high)
If yes, where does your body hurt?
Are you taking your medications as prescribed?
*
Yes
No
If no, please explain
Have your Medications/Vitamins/Supplements changed?
*
Yes
No
If yes, please provide the name of new medication, dosage, why it was prescribed, and the name of the prescribing physician.
Do you feel safe at home?
*
Yes
No
If no, please explain.
Area(s) I want to focus on today
*
Submit
Should be Empty: