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Therapist First Session Form
Therapist First Session Form
Status of Session
Yes it happened
Was this your first session with this client?
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?
Video on Gmeet
Audio on Gmeet
Please mention the medium of the session
Was this session observed
Name of Observer
Does the client come with a diagnosis
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
Disorders of Psychological Development
Behavioural & Emotional Disorders with Onset in Childhood and Adolescence
Unspecified Mental Disorder
Provisional Diagnosis: Organic & Symptomatic Mental Disorders
Organic Amnesic Syndrome (F04)
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
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)
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)
Sleep/Night Terrors (F51.4)
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)
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
Vocation & Career Change/Growth
Vicarious Trauma & Compassion Fatigue
What secondary financial concern did the client come with?
Budgeting & Savings
Vocation & Career Choices
What secondary Social concern did the client come with?
Problems in Family Dynamic
Separation & Divorce
Loneliness & Isolation
What secondary Environmental concern did the client come with?
Public vs Private Selves
Neglect & Endangerment
What secondary Spiritual concern did the client come with?
Grief, Bereavement, & Loss
Reasons for Living/Existential Questions
Relationship with God
What secondary Intellectual concern did the client come with?
Insufficient Intellectual Stimulation
What secondary Physical concern did the client come with?
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?
What secondary Geriatric concern did the client come with?
Mild Cognitive Impairment
What secondary Medical &/or Physical Health concern did the client come with?
Severe &/or Terminal Illness
Chronic Illness Management
What secondary Emotional concern did the client come with?
Sadness & Low Mood
Suicidal Ideation &/or Intent
What secondary Supervision (Psychology) concern did the client come with?
Psychology Student Therapy
Any other concerns?
Is the client at risk of suicide
What should the first responders do?
Who encouraged the client to come for therapy?
Doctor / Physician
Please specify who encouraged you to come to therapy
What was the focus of the session?
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
Did Not Check
No Homework Given
Please specify previous homework update
Homework This Session
What type of homework you have been given
Behaviour Focused Homework
Thought Focused Homework
What kind of Behaviour Focused Homework you are given
Recognizing bodily alerts
Breaking overthinking spirals with verbal interruptions
Please specify what other behaviour focused homework was given
What kind of Thought Focused Homework you are given
Assessment of bundaries
Please specify what other thought focused homework was given
What kind of Written Homework you are given
Self care tracker
Negotiables vs non negotiables
Please specify what other written homework was given
What kind of Psychiatric Homework you are given
Poisoning level check
Please specify what other psychiatric homework was given
Is there a barrier for the client to continue therapy
What do you think is the biggest barrier for the client to seek therapy further?
Therapy not needed
Resistance from client
Privacy & Confidentiality
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 ?
Did you experience Counter transference at any moment during the session ?
Do you need supervision for this client / concern
Was this the termination session?
Would you recommend Therapy packages to them ?
Which one would you recommend ?
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? :)
I feel okayish
Going with the flow
On top of the world!