Mid-Term Report

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Therapists Client Report

If you are human, leave this field blank.

Client Information

General information

Client ID

Client ID number given by the NHS, get this from Simon

Report Date

Today's date

Psychotherapist * Verity Jill Wendy Shabir Matthew Jennifer Sue Hazel Victoria

Therapist selection

Report For? * NHS England Health Board Insurance Legal Report Other Report For?

Who is the report for? (use other if not listed)

New Request for Sessions

Does this report indicate an request for additional sessions?

How Many Required? 4 6 8 10 12 Other How Many Required?

If yes, how many are you requesting?

Any Client Safety Risk? Yes Other Any Client Safety Risk?

Are there any suicidal or self-harm risks (other can be used for anything different)

What is the Risk? Self-harm Suicidal thoughts Has attempted suicide Other What is the Risk?

What is the risk? (use other to explain in more depth or another risk reported if required)

Learning

Major unavoidable factors, school education

Learning Adjustment Autism Dyspraxia ADHD Illiterate Language & grammar deficiency Illiterate & Language/grammar deficiency Asperger's syndrome Dyslexia Other Learning Adjustment

Only complete this if the client has any of the listed, use other if it is not listed

Learning Adjustment (2) Autism Dyspraxia ADHD Illiterate Language & grammar deficiency Illiterate & Language/grammar deficiency Asperger's syndrome Dyslexia Other Learning Adjustment (2)

Only complete if more than 1 (use other to list more than 2 if required)

Deaf Specific

Does the patient have specific mental health factors that are in relation to exclusion?

Language * BSL only (no English) BSL (limited English) BSL (cochlear supported) ISL (Irish) (No English) ISL (limited English) ISL (cochlear supported) ASL (American, no English) ASL (American, limited English) ASL (American, cochlear supported ISL (international, no English) ISL (International, limited English) ISL (cochlear supported) Other Language

Old info but need it entered

Education Hearing school Deaf unit (hearing school) Boarding school Deaf School Other Education

Type of education

Employment Hearing employer with deaf support Hearing employer with NO deaf support Hearing employer with interpreter support Hearing employer with NO interpreter support Deaf Employer Other Employment

Employer support

Employment Status Sick leave (less than 2 weeks) Sick leave (between 3 & 6 weeks) Long term sick (more than 6 weeks) Unemployed (between jobs) Unemployed (12 months to 2 years) Unemployed for over 2 years Attending Work Other Employment Status

Work attendance

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

Number 1 mental health Issue identified after first few sessions (this could of changed from the original assessment)

Initial Assessment * Mild Moderate Moderate/Severe Severe Other Initial Assessment

Counsellors assessment of the mental health of the client. (use other if required)

Current Assessment * Mild Moderate Moderate/Severe Severe

Counsellors assessment of the client on date of report.

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)

Additional mental health issue (only use, if this is in addition to the one above, in my experience clients have multiple issues which we can highlight and help with the funding for additional sessions)

Initial Assessment Mild Moderate Moderate/Severe Severe

As above

Current Assessment Mild Moderate Moderate/Severe Severe

As above

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)

Additional mental health issue if more than 2 listed (only use, if this is in addition to the one above)

Initial Assessment Mild Moderate Moderate/Severe Severe

As above

Current Assessment Mild Moderate Moderate/Severe Severe

As above

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

Explains how the patient feels from the counsellors sessions (counsellor assessment)

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)

Only use if multiple issues

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)

Only use if multiple issues

Disabilities/Pain/Illness

Disabilities/Pain/Illness Acquired brain injury Autism spectrum disorder Cancer Chronic pain Dementia Diabetes Epilepsy Limb loss Migraine Multiple sclerosis Musculoskeletal disorders Schizophrenia Tinnitus Visual impairment (Usher) Other Disabilities/Pain/Illness

Explains any additional factors that can be contributing to poor mental health

Disabilities/Pain/Illness (2) Acquired brain injury Autism spectrum disorder Cancer Chronic pain Dementia Diabetes Epilepsy Limb loss Migraine Multiple sclerosis Musculoskeletal disorders Schizophrenia Tinnitus Visual impairment (Usher) Other Disabilities/Pain/Illness (2)

Only use if more than 1

Disabilities/Pain/Illness (3) Acquired brain injury Autism spectrum disorder Cancer Chronic pain Dementia Diabetes Epilepsy Limb loss Migraine Multiple sclerosis Musculoskeletal disorders Schizophrenia Tinnitus Visual impairment (Usher) Other Disabilities/Pain/Illness (3)

Only use if more than 2

Victim

Major contributing factors to mental health decrease

Factor-in Issues Sexually abused (as a child) Sexually abused (teenager) Sexually abused Physically abused (child) Physically abused (teenager) Physically abused Bullied (hearing education, early learning years) Bullied (hearing education, teenage learning years) Bullied (boarding school) Other Factor-in Issues

Major causes of mental health disorders, use other if not listed

Factor-in Issues (2) Sexually abused (as a child) Sexually abused (teenager) Sexually abused Physically abused (child) Physically abused (teenager) Physically abused Bullied (hearing education, early learning years) Bullied (hearing education, teenage learning years) Bullied (boarding school) Other Factor-in Issues (2)

As above if more than 1

Factor-in Issues (3) Sexually abused (as a child) Sexually abused (teenager) Sexually abused Physically abused (child) Physically abused (teenager) Physically abused Bullied (hearing education, early learning years) Bullied (hearing education, teenage learning years) Bullied (boarding school) Other Factor-in Issues (3)

As above, use other if more than 3

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

Addictions? (2) Cannabis Cocaine Social drugs OCD Food Alcohol Other Addictions? (2)

Additional addictions if any?

Type of User? Daily Light user Social user Daily routine (OCD) Other Type of User?

Frequency of use

Client Support Network

Who helps the client

Who is the main carer for the client? * Self Mother/Father Social Worker Grandparent Other Who is the main carer for the client?

Care of the client explained

Explain if there is something we need to bring to the attention of the doctor or social worker for example (client consent must be obtained to complete this section)

Risk

Potential Risk to Self?

Probability is Low Probability is High Other Potential Risk to Self?

Life or harm risk

Potential Risk to Others

Probability is Low Probability is High Other Potential Risk to Others

Possible injury to others

Additional Information

Any additional Information?

Submit