Executive Function Coaching Referral Checklist for Mental Health Providers

Executive Function Coaching Referral Checklist for Mental Health Providers

For Mental Health Providers and Discharge Planners
Use this checklist to determine whether a client may benefit from executive function coaching as part of their post‑discharge or ongoing treatment plan. Coaching provides non‑clinical, practical support that strengthens follow‑through, routines, and daily functioning. You’re welcome to print the checklist for future use or include your results in your documentation, or review it with your client.
1. Clinical Stability & Readiness

Client is clinically stable and safeEngaged in outpatient therapy, psychiatry, or step‑down careDemonstrates insight into treatment goalsMotivated for recovery but struggling with day‑to‑day implementationWould benefit from additional structure between clinical sessions
2. Daily Functioning Risks

Frequently misses or forgets appointmentsDifficulty managing medications or health routinesDisorganization affecting home, school, or workOverwhelm during unstructured timeDifficulty transitioning from structured care to independent routinesCaregiver responsibilities and tasks feel unmanageableReturning to academics, work, or caregiving with limited support
3. Executive Function Indicators

Trouble starting tasks (task initiation challenges)Poor follow‑through on goals, recommendations, or assignmentsTime‑management difficulties (lateness, losing track of time, over‑scheduling)Difficulty planning or breaking tasks into stepsEmotional regulation challenges impacting functioningCognitive overload or shutdown when demands increaseWould benefit from external accountability to stay consistentWould benefit from predictable routines and systems
4. Behavioral Patterns That Interfere With Progress

Avoidance despite insight and motivation“All‑or‑nothing” thinking that blocks progressHigh anxiety around tasks, decisions, or responsibilitiesRepeated crises due to disorganization or missed tasksDifficulty applying therapeutic skills outside sessionsFamily/caregivers reporting overwhelm or burnout
5. Ideal Coaching Fit Indicators

Client responds well to collaborative, strengths‑based supportClient benefits from structure, reminders, and accountabilityClient needs help translating treatment recommendations into daily habitsClient is transitioning from inpatient, PHP, or IOP and needs scaffoldingCoaching would reduce pressure on the clinical team by supporting follow‑through
Referral Guidance

If 3 or more boxes are checked in any section or if the client is clinically stable but struggling with daily functioning, a referral to executive function coaching may provide meaningful support and improve treatment outcomes.
Optional: Request Flyers, Information, or a Brief Consultation

You can also refer a client or ask a quick question here if that’s easier.
Name

First NameLast Name
Agency/Practice
Email
example@example.com
What are you requesting?

Flyers / shareable materialsProgram informationA brief consultationI have a question (Enter question below)Other
Have a quick question? A senior staff member will respond to your question, we don’t use automated or sales follow‑ups.
Want to refer a client?

Yes, please send me the referral form (takes less than 2 minutes)
Should be Empty:

Executive Function Coaching Referral Checklist for Mental Health Providers

Referral Guidance

Optional: Request Flyers, Information, or a Brief Consultation