Before age 18, did you experience any of the following?
Assessment Details · Adverse Experiences · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
10 fields across 3 sections
Explore the client's anxiety pattern, triggers, and existing coping repertoire.
Assessment Details · Assessment · Risk Flags · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
13 fields across 4 sections
Update the biopsychosocial picture at a treatment milestone.
Assessment Details · Updates Since Last Assessment · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
11 fields across 3 sections
Explore the client's relationship with food, body image, and eating behaviors.
Assessment Details · Assessment · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
12 fields across 3 sections
Quick mental status check for use at routine follow-up visits.
Assessment Details · Brief MSE · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
12 fields across 3 sections
Rate your pain and its impact on daily life over the past week.
Assessment Details · Pain Impact · Pain Description · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
21 fields across 4 sections
Quick screen to identify clients who need a full risk assessment.
Assessment Details · Screening Items · Disposition · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
10 fields across 4 sections
Rate how often you experience the following at work.
Assessment Details · Emotional Exhaustion · Depersonalization & Efficacy · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
18 fields across 4 sections
Track recovery progress and adjust recommendations.
Assessment Details · Since Last Check-In · Plan · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
14 fields across 4 sections
Assess current career context, aspirations, and skill gaps.
Assessment Details · Career Context · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
12 fields across 3 sections
Screen for indicators of abuse, neglect, or unsafe caregiving conditions.
Assessment Details · Safety Indicators · Mandatory Reporting Notes · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
10 fields across 4 sections
Focused screen of cognitive domains for suspected cognitive impairment.
Assessment Details · Domains Assessed · Notes · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
9 fields across 4 sections
Ask each item in order. A 'yes' response to any item warrants further assessment.
Assessment Details · Screening Items · Follow-Up Detail · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
12 fields across 4 sections
Rate how often you have experienced the following in the past 30 days.
Assessment Details · Compassion Fatigue Symptoms · Risk Flags · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
13 fields across 4 sections
Rapid screen to determine if the client requires an immediate crisis-level response.
Assessment Details · Crisis Indicators · Immediate Action · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
10 fields across 4 sections
Screen sensitively for current or past intimate partner violence.
Assessment Details · Screening Items · Safety Planning · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
10 fields across 4 sections
Rate how often each statement applies to you.
Assessment Details · Attitudes & Behaviors · Risk Flags · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
17 fields across 4 sections
Track symptom trajectory and medical stability at follow-up visits.
Assessment Details · Status Since Last Visit · Notes · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
9 fields across 4 sections
Assess the client's physical environment for safety hazards.
Assessment Details · Environmental Factors · Notes · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
9 fields across 4 sections
Rate the likelihood of dozing or falling asleep in each situation, as opposed to just feeling tired.
Assessment Details · Chance of Dozing · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
18 fields across 3 sections
Gather detailed family structure and social support information.
Assessment Details · Family & Social History · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
13 fields across 3 sections
Evaluate how pain affects the client's ability to perform daily activities.
Assessment Details · Functional Limitation · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
17 fields across 3 sections
Over the last 2 weeks, how often have you been bothered by the following problems?
Assessment Details · Symptom Frequency · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
17 fields across 3 sections
Rate how often you have experienced the following in the past 2 weeks.
Assessment Details · Symptom Frequency · Risk Flags · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
18 fields across 4 sections
Screen for risk factors requiring immediate clinical attention.
Assessment Details · Risk Domains Screened · Clinical Notes · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
10 fields across 4 sections
Define specific, measurable coaching goals and success criteria.
Assessment Details · Goals · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
12 fields across 3 sections
Synthesize intake findings into an initial clinical formulation and plan.
Assessment Details · Summary & Formulation · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
12 fields across 3 sections
Rate the current severity of your sleep difficulties over the past 2 weeks.
Assessment Details · Sleep Difficulty · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
17 fields across 3 sections
Review current lifestyle habits across key wellness categories.
Assessment Details · Habits Reviewed · Notes · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
9 fields across 4 sections
Select the words that best describe your pain right now.
Assessment Details · Pain Descriptors · Present Pain Intensity · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
11 fields across 4 sections
Mental status exam focused on acute risk and safety in a crisis presentation.
Assessment Details · Presentation · Risk Indicators · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
11 fields across 4 sections
Introductory intake for building rapport while gathering essential history.
Assessment Details · About the Client · History · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
15 fields across 4 sections
Complete at each follow-up visit to track pain trajectory and treatment response.
Assessment Details · Pain Level Since Last Visit · Clinical Notes · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
15 fields across 4 sections
Ask about episodes of sudden, intense fear or discomfort in the past month.
Assessment Details · Panic Symptoms Endorsed · Episode History · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
14 fields across 4 sections
In the past month, how much were you bothered by the following?
Assessment Details · Symptom Severity · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
24 fields across 3 sections
A brief two-item screen for depressive symptoms, used to determine whether a full PHQ-9 is warranted.
Assessment Details · Symptom Frequency · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
10 fields across 3 sections
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Assessment Details · Symptom Frequency · Risk Flags · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
19 fields across 4 sections
Assess status and safety following a recent crisis episode or discharge from higher level of care.
Assessment Details · Current Status · Notes · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
10 fields across 4 sections
For use with clients who have given birth in the past 12 months. Reflect on how you have felt over the past 7 days.
Assessment Details · Symptom Frequency · Risk Flags · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
20 fields across 4 sections
Evaluate the impact of PTSD symptoms on daily functioning.
Assessment Details · Functional Impact · Notes · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
17 fields across 4 sections
Guide for a structured clinical interview assessing PTSD symptom clusters.
Assessment Details · Symptom Clusters · Risk Flags · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
13 fields across 4 sections
Rate your agreement with each statement about handling stress.
Assessment Details · Resilience Statements · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
12 fields across 3 sections
Develop a personalized safety plan with the client for use during a crisis.
Assessment Details · Safety Plan Components · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
16 fields across 3 sections
A brief 5-item screen for eating disorder risk.
Assessment Details · Screening Items · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
15 fields across 3 sections
Evaluate history and current risk of self-harming behavior.
Assessment Details · History & Current Risk · Safety Plan · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
13 fields across 4 sections
Capture client reflections immediately following a coaching session.
Assessment Details · Reflection · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
11 fields across 3 sections
Summarize patterns observed in the client's sleep diary and adjust the treatment plan.
Assessment Details · Diary Summary · Plan Adjustments · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
14 fields across 4 sections
Review current sleep-related habits and environment.
Assessment Details · Habits Reviewed · Notes & Recommendations · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
10 fields across 4 sections
Rate how much fear or avoidance you experience in the following situations.
Assessment Details · Fear / Avoidance · Functional Impact · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
20 fields across 4 sections
Document observations across all standard MSE domains.
Assessment Details · Appearance & Behavior · Speech & Mood · Thought Process & Content
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
17 fields across 4 sections
Assess substance use history and current use patterns.
Assessment Details · Substances Used (Lifetime) · Use Patterns · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
14 fields across 4 sections
Complete collaboratively with the client to plan for moments of crisis.
Assessment Details · Safety Plan Steps · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
17 fields across 3 sections
Ask about lifetime exposure to potentially traumatic events. Client may decline to answer any item.
Assessment Details · Exposure History · Clinical Notes · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
13 fields across 4 sections
Rate how often you have experienced the following in the past month.
Assessment Details · Symptom Frequency · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
17 fields across 3 sections
Evaluate historical and current factors associated with violence risk.
Assessment Details · Risk Factors · Formulation & Plan · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
11 fields across 4 sections
Rate your agreement with each statement about your current wellbeing.
Assessment Details · Wellbeing Statements · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
16 fields across 3 sections
Assess workplace factors contributing to burnout risk.
Assessment Details · Organizational Factors · Notes · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
16 fields across 4 sections
Rate your agreement with each statement about your workplace wellbeing.
Assessment Details · Workplace Wellbeing · Signatures
- Client Name
- Date of Birth
- Client ID / MRN
- Date of Assessment
- Clinician / Coach
13 fields across 3 sections
