Mid-Term Report Mid-Term Report If you are human, leave this field blank. Client Information General information Client ID Report Date Today's date Psychotherapist * Verity Jill Wendy Shabir 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
