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Treatment Progress
Name:
Filled Out By:
Date:
If you have more than one session here today, this form is being filled out number of sessions to date?
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Please take a few moments to relax and gather your thoughts, then reflect upon the following questions:
1) Since the
last treatment session
have you seen any of the following (please select a number from the scale below next to any that apply):
1= a small amount; 2= a moderate amount; 3= a large amount
0
1
2
3
Increased impulsivity
0
1
2
3
Spaciness or foggy thinking
0
1
2
3
Increased agressiveness
0
1
2
3
Feeling, acting drunk
0
1
2
3
Hyper focus (over focus)
0
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3
Decreased motivation
0
1
2
3
Increased agitation
0
1
2
3
Decreased energy and speed
0
1
2
3
Increased anxiety
0
1
2
3
Depression
0
1
2
3
Increased anger
0
1
2
3
Loss of emotional control
0
1
2
3
Obsessive thoughts
0
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3
Increased irritability
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3
Compulsive behaviours
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3
Increased night terrors
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3
Difficulty falling asleep
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3
Decreased ability to do tasks requiring steps
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3
Increased nightmares
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3
Increased snoring
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3
Increased body tension
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3
Disrupted sleep (trouble remaining asleep)
0
1
2
3
Increased tics
0
1
2
3
Decreased pain threshold
0
1
2
3
Increased headaches
0
1
2
3
Increased hyperactivity
Other effects you have experienced or observed? (please explain):
2) What positive changes have you noticed? Have there been any indications of benefits in addition to what you have previously mentioned or discussed? Please explain your observations.
3) Since the last session, have you seen any backsliding or regression in any of the benefits previously experienced or that others have noticed? If so, please elaborate.
4) Please note whether there has been any changes in medication(s) since the last session. Include any alternative treatments or non-prescription medications. If yes, please explain.
5) Please list below any treatment-related questions or concerns you want to discuss with your therapist or other professionals you are working with: