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Mid-Term Report
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Mid-Term Report
Mid-Term Report
Client Information
General information
Client ID
Report Date
Today's date
Psychotherapist
*
Verity
Jill
Wendy
Caroline
Matthew
Jennifer
Sue
Hazel
Victoria
Jacob
Johanna
Report For?
*
NHS England
Health Board
Insurance
Legal Report
Other
Report For?
Mental Health Issues
The major mental health condition/issue (the number 1 reason for counselling?
Mental Health Issue
*
Anger
Anxiety
Bipolar
Borderline Personality Disorder (BPD)
Depression
Panic
Post-Traumatic Stress Disorder (PTSD)
Phobias
Stress
Schizophrenia
Trauma
Other
Mental Health Issue
Initial Assessment
*
Mild
Moderate
Moderate/Severe
Severe
Other
Initial Assessment
Current Assessment
*
Mild
Moderate
Moderate/Severe
Severe
Note, if other selected or you feel more information needs to be explained
Mental Health Issues
Co-existing mental health issue
Co-Existing (MHI)
Anger
Anxiety
Bipolar
Borderline Personality Disorder (BPD)
Depression
Panic
Post-Traumatic Stress Disorder (PTSD)
Phobias
Stress
Schizophrenia
Trauma
Insomnia
Other
Co-Existing (MHI)
Initial Assessment
Mild
Moderate
Moderate/Severe
Severe
Current Assessment
Mild
Moderate
Moderate/Severe
Severe
Note, if other selected or you feel more information needs to be explained
Mental Health Issues
Co-Existing (MHI)
Anger
Anxiety
Bipolar
Borderline Personality Disorder (BPD)
Depression
Panic
Post-Traumatic Stress Disorder (PTSD)
Phobias
Stress
Schizophrenia
Trauma
Insomnia
Other
Co-Existing (MHI)
Initial Assessment
Mild
Moderate
Moderate/Severe
Severe
Current Assessment
Mild
Moderate
Moderate/Severe
Severe
Note, if other selected or you feel more information needs to be explained
Contributing factors
Emotional Factors for Mental Health Decline
Emotional Health
Worry (something dreadful will happen)
Shame (feel inadequate))
Isolated (lonely, no friends)
Worry (pending homelessness)
Death of a parent
Death of a grandparent
Terminal Illness (close friend)
Terminal Illness (family member)
Other
Emotional Health
Initial Assessment
Mild
Moderate
Moderate/Severe
Severe
Current Assessment
Mild
Moderate
Moderate/Severe
Severe
Note, if other selected or you feel more information needs to be explained
Emotional Health Additional
Emotional Health (2)
Worry (something dreadful will happen)
Shame (feel inadequate))
Isolated (lonely, no friends)
Worry (pending homelessness)
Death of a parent
Death of a grandparent
Terminal Illness (close friend)
Terminal Illness (family member)
Other
Emotional Health (2)
Initial Assessment
Mild
Moderate
Moderate/Severe
Severe
Current Assessment
Mild
Moderate
Moderate/Severe
Severe
Note, if other selected or you feel more information needs to be explained
Emotional Health
Emotional Health (3)
Worry (something dreadful will happen)
Shame (feel inadequate))
Isolated (lonely, no friends)
Worry (pending homelessness)
Death of a parent
Death of a grandparent
Terminal Illness (close friend)
Terminal Illness (family member)
Other
Emotional Health (3)
Initial Assessment
Mild
Moderate
Moderate/Severe
Severe
Current Assessment
Mild
Moderate
Moderate/Severe
Severe
Note, if other selected or you feel more information needs to be explained
Addictions
Does the client have any addictions that contribute to the mental health condition?
Addictions?
Cannabis
Cocaine
Social drugs
OCD
Food
Alcohol
Other
Addictions?
Does the client have any addictions
Type of User?
Daily
Light user
Social user
Daily routine (OCD)
Other
Type of User?
Frequency of use
Initial Assessment
Mild
Moderate
Moderate/Severe
Severe
As above
Current Assessment
Mild
Moderate
Moderate/Severe
Severe
As above
Any Additional Addictions Information?
New Request for Sessions
Does this report indicate an request for additional sessions?
Is There a Need for More Sessions?
*
No
Yes
If Yes, How Many Required?
4
6
8
10
12
Other
If Yes, How Many Required?
If yes, how many are you requesting?
Reason for Request of Additional Sessions?
Any additional Information?
Client Safety
Any Client Safety Risk?
No
Yes
Low
Moderate
Other
Any Client Safety Risk?
What is the Risk?
No Risk
Self-harm
Suicidal thoughts
Has attempted suicide
Other
What is the Risk?
Note, if you feel more information needs to be explained
Additional Information
Additional Information
Any additional Information?
Submit
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