~ Nature Trail Eye Play~

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Readers, this a helpful tool to help psychotherapy clients, who distressed, often struggle with their memory, focus and organization. The form, filled out before coming into the session, is a great way to begin discussion, keep things on track, and reduce confusion. The author offers it free, asking only that the source information at the bottom of the page be maintained on all copies. A print-friendly version can be emailed to you by leaving a comment.







Client Psychotherapy Appointment Communication Tickler

Name                                                                                               Date

Appointment Time:                 must leave by_______    will call to reschedule    please call me
Usual Visit Frequency:    varies    2+ per week    weekly        2-3/month    monthly
Nature of Today’s Visit:    first    as scheduled    extra        emergency    make-up appt
Next Visit:    discuss now    as scheduled    request extra    will call you    please call me

General Info:    name        phone#        address        household    insurance
Schedule:      travel        guests        appointments    other        permanent
Medical:    plans        providers    medications    diagnoses    treatment

For You
Updates:    bringing next time    will send/drop off    let’s discuss     on back/attached
Paperwork:    to fill out and/or sign    requesting info    for your use    returning as requested
Other:    things I’ve created    things about me        donations    invitation/request    info

Concerns:    schedule/availability    client-therapist relationship    personal safety
Stressors:    trauma         conflict        uncertainty/confusion        loss/change
Relationships:    past family    current family    friends/social    occupational    other
Focus:    process feelings        develop skills    gain insight    find solutions    other
Follow-thru:    assignments    resolutions    insights        progress on goals


Summarize the following:
physical condition
compliance with treatment
cognitive functioning
ability to meet responsibilities
use of coping skills
primary thoughts

Copyright 2007 by Molly J. Efflandt, BSW