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Therapist First Session Form
Therapist First Session Form
Appointment Id:
Session Date
Session Time
Status of Session
Yes it happened
Cancelled
Rescheduled
No Show
Was this your first session with this client?
Yes
No
Emergency Contact Name
Emergency Contact Number
Relationship With Client
Did the session start and end on time?
Yes to both
No to both
Started on time, extended end
Started late, ended on time
How did the session happen?
In Person
Video on Gmeet
Audio on Gmeet
Whatsapp call
Phone call
Zoom
Skype
Other
Please mention the medium of the session
Was this session observed
No
Yes
Name of Observer
Does the client come with a diagnosis
Yes
No
What are their diagnoses?
Organic & Symptomatic Mental Disorders
Mental & Behavioural Disorders due to Psychoactive Substance Use
Schizophrenia, Schizotypal, & Delusional Disorders
Mood [Affective] Disorder
Neurotic, Stress-Related, & Somatoform Disorders
Behavioural Syndromes Associated with Physiological Disturbances & Physical Factors
Disorders of Adult Personality & Behaviour
Intellectual Disability
Disorders of Psychological Development
Behavioural & Emotional Disorders with Onset in Childhood and Adolescence
Unspecified Mental Disorder
Provisional Diagnosis: Organic & Symptomatic Mental Disorders
Dementia (F03.90)
Organic Amnesic Syndrome (F04)
Delirium (F05.9)
Provisional Diagnosis: Mental & Behavioural Disorders due to Psychoactive Substance Use
Harmful Use (F19.10)
Dependence Syndrome (F10.2)
Amnesic Syndrome (F04)
Provisional Diagnosis: Schizophrenia, Schizotypal, & Delusional Disorders
Schizophrenia (F20.9)
Schizotypal Disorder (F21)
Persistent Delusional Disorder (F22.9)
Acute & Transient Psychotic Disorder (F23)
Induced Delusional Disorder (F28)
Schizoaffective Disorder (F25.9)
Other/Unspecified Psychotic Disorder (F29)
Provisional Diagnosis: Mood [Affective] Disorder
Manic/Hypomanic Episode (first episode) (F30.9)
Bipolar Affective Disorder (F31.3)
Depressive Episode (first episode) (F32.1)
Recurrent Depressive Disorder (F33.9)
Persistent Depressive Disorder (Dysthymia) (F34.1)
Cyclothymia (F34.0)
Other/Unspecified Mood Disorder (F39)
Provisional Diagnosis: Neurotic, Stress-Related, & Somatoform Disorders
Agoraphobia (with or without Panic Disorder) (F40.01)
Social Phobia (F40.1)
Specific (isolated) Phobia (F40.2)
Panic Disorder (F41)
Generalised Anxiety Disorder (F41.1)
Mixed Anxiety & Depressive Disorder (F41.8)
Obsessive-Compulsive Disorder (F42)
Acute Stress Reaction (F43)
Post-Traumatic Stress Disorder (F43.1)
Adjustment Disorder (F43.2)
Other/Unspecified Reactions to Severe Stress (F43.8)
Dissociative Disorders (F44.81)
Somatization Disorder (F45)
Undifferentiated Somatoform Disorder (F45.1)
Hypochondriacal Disorder (F45.21)
Somatoform Autonomic Dysfunction (F45.3)
Persistent Somatoform Pain Disorder (F45.4)
Other/Unspecified Somatoform Disorder (F45.9)
Depersonalisation-Derealisation Syndrome (F48.1)
Provisional Diagnosis: Behavioural Syndromes Associated with Physiological Disturbances & Physical Factors
Anorexia Nervosa (F50)
Bulimia Nervosa (F50.2)
Overeating Associated with Psychological Disturbances (F50.4)
Other/Unspecified Eating Disorder (F50.9)
Nonorganic Insomnia (F50.01)
Nonorganic Hypersomnia (F51.19)
Nonorganic Disorder of Sleep-Wake Schedule (F51.2)
Somnanbulism (F51.3)
Sleep/Night Terrors (F51.4)
Nightmares (F51.5)
Other/Unspecified Sleep Disorder (F51.9)
Specific Sexual Dysfunction (F52)
Other/Unspecified Sexual Dysfunction (F52.9)
Mental & Behavioural Disorders associated with Puerperium (Postpartum MH Disorder) (F53)
Abuse of Non-Dependence Producing Substances (F55)
Provisional Diagnosis: Disorders of Adult Personality & Behaviour
Specific Personality Disorder (F60)
Mixed Personality Disorder (F61)
Habit & Impulse-Control Disorder (F63.9)
Specific Disorder of Gender Identity Disorder (Gender Dysphoria)Preference (Paraphilia) (F64.9)
Specific Disorder of Sexual Preference (Paraphilia) (F65.9)
Other/Unspecified Disorder of Sexual Preference (F66)
Provisional Diagnosis: Intellectual Disability
Mild Intellectual Disability (F70)
Feeding Disorder of Infancy & Childhood (F71)
Severe Intellectual Disability (F72)
Profound Intellectual Disability (F73)
Other/Unspecified Intellectual Disability (F79)
Provisional Diagnosis: Disorders of Psychological Development
Specific Speech Articulation Disorder (F80)
Expressive &/or Receptive Language Disorder (F80.2)
Acquired Aphasia with Epilepsy (Landau-Kleffner Syndrome) (F80.3)
Other/Unspecified Disorder of Speech and Language (F80.9)
Specific Learning Disorder (i.e. Dyslexia, Dysgraphia, Dyscalculia) (F81.2)
Other/Unspecified Learning Disorder (F81.9)
Specific Developmental Disorder of Motor Function (i.e. Dyspraxia) (F82)
Autism Spectrum Disorders (F84)
Other/Unspecified Pervasive Developmental Disorders (F84.9)
Provisional Diagnosis: Behavioural & Emotional Disorders with Onset in Childhood and Adolescence
Attention-Deficit/Hyperactivity Disorder (i.e. Hyperkinetic Disorders) (F90)
Conduct Disorder (F91.9)
Oppositional Defiant Disorder (F91.3)
Other/Unspecified Conduct Disorder (F91.8)
Separation Anxiety Disorder of Childhood (F93)
Phobic Anxiety Disorder of Childhood (F40.8)
Social Anxiety Disorder of Childhood (F40.11)
Sibling Rivalry Disorder (F93.3)
Other/Unspecified Childhood Emotional Disorder (F93.9)
Elective Mutism (F94)
Reactive Attachment Disorder of Childhood (F94.1)
Disinhibited Attachment Disorder of Childhood (F94.2)
Other/Unspecified Childhood Disorder of Social Functioning (F94.9)
Transient Tic Disorder (F95)
Chronic Motor/Vocal Tic Disorder (F95.1)
Tourette's Syndrome (F95.2)
Other/Unspecified Tic Disorder (F95.9)
Nonorganic Enuresis &/or Encopresis (F98.1)
Feeding Disorder of Infancy & Childhood (F98.29)
Stereotyped Movement Disorder (F98.4)
Stuttering/Stammering (F98.5)
Cluttering (F80.81)
Provisional Diagnosis: Unspecified Mental Disorder
Mental Disorder NOS (F99)
Do you want to provide a provisional diagnosis?
What primary concern did the client come with?
Occupational: Satisfaction, productivity and enrichment
Financial: Building a secure future
Social: Supportive network of people
Spiritual: Finding meaning for living
Environmental: A safe, secure & just world
Intellectual: Growth and passion for life
Physical: Sleep, nutrition & health
Emotional: Coping with adversity
Medical: Psychiatric and other Medical Issues
Neurological and Neurodevelopmental: Child, Adoloscent & Adulthood
Geriatric: Age> 48, Aging and Empty Nest
Personhood: Self Identity and the Ikigai
Psychology Supervision: Students & Practitioners of Psychology
What secondary occupational concern did the client come with?
Workplace/Institutional (Academic) Problems
Work-Life Balance
Burnout
Vocation & Career Change/Growth
Vicarious Trauma & Compassion Fatigue
Harassment
What secondary financial concern did the client come with?
Future Planning
Budgeting & Savings
Debt
Vocation & Career Choices
What secondary Social concern did the client come with?
Interpersonal Issues
Relationship Issues
Problems in Family Dynamic
Parenting Issues
Adoption
Family Planning
Infidelity
Separation & Divorce
Loneliness & Isolation
Friendships
What secondary Environmental concern did the client come with?
Adjustment Issues
Public vs Private Selves
Physical Abuse
Emotional Abuse
Sexual Abuse
Domestic Violence
Neglect & Endangerment
Safety Concerns
What secondary Spiritual concern did the client come with?
Death
Grief, Bereavement, & Loss
Reasons for Living/Existential Questions
Trauma
Relationship with God
What secondary Intellectual concern did the client come with?
Socioemotional Skills
Insufficient Intellectual Stimulation
What secondary Physical concern did the client come with?
Appetite Disturbances
Sleep Disturbances
Menstrual Disturbances
Disturbance in Bowel Function &/or Bladder ActivityDisturbance in Sexual Performance
Disturbance in Sexual Performance
Substance Misuse & Dependence
What secondary Self & Personhood concern did the client come with?
Gender
Sexuality
Paraphilias
Self-Esteem
Self-Worth
Self-Identity
What secondary Geriatric concern did the client come with?
Mild Cognitive Impairment
Pseudodementia
What secondary Medical &/or Physical Health concern did the client come with?
Physical Disability
Severe &/or Terminal Illness
Chronic Illness Management
Chronic Pain
Psychosomatic Concerns
What secondary Emotional concern did the client come with?
Stress
Emotional Regulation
Sadness & Low Mood
Anxiety (General)
Self-Harm
Suicidal Ideation &/or Intent
Behavioural Issues
Behavioural Addictions
What secondary Supervision (Psychology) concern did the client come with?
Professional Supervision
Psychology Student Therapy
Any other concerns?
Is the client at risk of suicide
Yes
No
Unsure
Others
Please specify
What should the first responders do?
Who encouraged the client to come for therapy?
Self
Family
Friend
Spouse
Psychiatrist
Doctor / Physician
School
College Requirement
Professional Requirement
Therapist/Psychologist
Corporate
Others
Please specify who encouraged you to come to therapy
What was the focus of the session?
Solution
Awareness
Venting
Other
Please specify what was the other focus of the session
What stage is the client at?
Orientation - Learning stage, little to no insight
Identification - Laying out the problems in different areas
Exploration - Finding deeper connections, making progress
Resolution - Making decisions, taking action, active
Maintenance - No clinical issues, healthy states
Previous Homework
Done
Not Done
Did Not Check
No Homework Given
Other
Please specify previous homework update
Homework This Session
Given
Not Given
What type of homework you have been given
Behaviour Focused Homework
Thought Focused Homework
Written Homework
Psychiatric
What kind of Behaviour Focused Homework you are given
Grounding
Recognizing bodily alerts
Commitment milestones
Box breathing
Breaking overthinking spirals with verbal interruptions
Others
Please specify what other behaviour focused homework was given
What kind of Thought Focused Homework you are given
Reflections/ prompters
Assessment of bundaries
Affirmations
Thought record
CBT worksheet
Others
Please specify what other thought focused homework was given
What kind of Written Homework you are given
Journaling
Lists
Self care tracker
Grief letter
Negotiables vs non negotiables
Others
Please specify what other written homework was given
What kind of Psychiatric Homework you are given
Sleep
Appetite
Poisoning level check
Others
Please specify what other psychiatric homework was given
Is there a barrier for the client to continue therapy
Yes
No
What do you think is the biggest barrier for the client to seek therapy further?
Stigma
Therapeutic Alliance
Financial Constraints
Insight
Unrealistic Expectations
Therapy not needed
Partner/ family
Resistance from client
Privacy & Confidentiality
Unsure
Others
Please mention the other barrier for the client
Please mention your understanding of the above mentioned barrier(s):
Did you experience Transference at any moment during the session ?
Yes
No
Did you experience Counter transference at any moment during the session ?
Yes
No
Do you need supervision for this client / concern
Yes
No
Was this the termination session?
Yes
No
Would you recommend Therapy packages to them ?
Yes
No
Which one would you recommend ?
1 Session
3 Session
5 Sessions
How did you feel about the session?
It was Terrible
It was Okay
It was Good
It was Amazing
What Self Help Product would help the client after this session?
Doodle books (journaling)
Pocket notebooks (list making)
Periodic Table of Emotions (emotional regulation)
Angry and After (Emotional regulation)
IKIGAI Cards (purpose, self identity)
Gratitude Journal (Depression, Self image)
Heart It Out Merchandise - Badges
When would you like reminder to check-in on this client?
How do you feel as a therapist after the session? :)
I have no idea how to proceed
Need to read a lot to move ahead
Can figure this out!
It's my thing- I do this well
This is easy & I can kick ass!
How do you feel as a human after the session? :)
Exhausted af
Meh, tired
I feel okayish
Going with the flow
On top of the world!