* = Required Information
Client Name
*
Date of Session
*
Location/Site
Contact Person
Staff assessment of client progress since last appointment (including emotional and behavioral highlights and significant events/incidents):
Staff Name Completing Above:
Below to be completed by the therapist, signed and returned with the client.
Type of Therapy
Psychological Therapy
Speech Therapy
Physical Therapy
Occupational Therapy
Other
Group
Individual
Client Participation
Flat
Bright
Labile
Tearful
Anxious
Angry
Client Affect
Engaged
Minimally Engaged
Not Engaged/Refused
Key Topic(s) Discussed
Progress since last appointment
Recommendations to Client
Recommendations to Staff/Caregivers
Plan
Continue
Terminate
Revise
Explain
Therapist Name:
*
Date:
Date and Time of Next Appointment
Submit