Mid-Term Report

Client Information

General information
Today's date

Mental Health Issues

The major mental health condition/issue (the number 1 reason for counselling?

Mental Health Issues

Co-existing mental health issue

Mental Health Issues

Contributing factors

Emotional Factors for Mental Health Decline

Emotional Health Additional

Emotional Health


Does the client have any addictions that contribute to the mental health condition?
Does the client have any addictions
Frequency of use
As above
As above

New Request for Sessions

Does this report indicate an request for additional sessions?
If yes, how many are you requesting?
Any additional Information?

Client Safety

Additional Information

Any additional Information?