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Chief Complaint
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Presenting Symptoms:
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Objective Findings: See MSE
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Orientation
• • •
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Rapport
• • •
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Appearance:
• • •
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Mood:
• • •
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Affect:
• • •
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Speech:
• • •
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Thought Content and Process:
• • •
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Insight:
• • •
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Judgement:
• • •
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Objective Findings Comments:
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Session Participation (Engagement):
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Session Participation:
• • •
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Session Participation Comments:
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Start and Stop Time:
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Minutes spent doing therapy only:
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Assessment (Mental Health Prognosis):
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Assessment (Mental Health Prognosis):
• • •
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Assessment Comments:
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Problem:
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Problem:
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Plan:
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Plan:
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Goal #1
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Goal #1
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Goal #1:
• • •
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Goal #2
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Goal #2
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Goal #2:
• • •
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Goal #3
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Goal #3
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Goal #3:
• • •
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Therapy
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Therapy Type:
• • •
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Focus:
• • •
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Interventions:
• • •
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Therapy Comment:
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Response to Treatment Plan:
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Homework:
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Total Time:
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