PSYCHOTHERAPY ASSESSMENT CHECKLIST (1/01) Psychotherapy Research Program at HMS, Leigh McCullough Ph.D. PERSONAL DATA Name Date Address Age DOB / / Sex M F Home Phone ( ) Occupation Work Phone ( ).
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How to fill out the psychotherapy research program at HMS, Leigh McCullough Ph online
This guide provides clear and supportive instructions for completing the psychotherapy research program form at HMS, facilitating your engagement in the therapeutic process. By following these steps, you can ensure a comprehensive submission that reflects your experiences and needs.
Follow the steps to complete the form successfully.
- To begin, locate and press the ‘Get Form’ button. This will allow you to access the form needed for your submission.
- In the personal data section, enter your name, date, and address in the designated fields. Provide your age and date of birth, and select your gender from the options provided (M or F).
- Continue by filling in your home and work phone numbers, occupation, years of education, marital status, and insurance company details. It is important to ensure accuracy in this section for future reference.
- In the main problems section, list the major issues for which you seek therapy. Rate the severity of each issue from 1 (not a problem) to 10 (couldn't be worse). Consider taking your time to accurately reflect your feelings.
- Describe your motivation for seeking therapy at this time by providing thoughtful insights regarding your current circumstances. Utilize additional space on the back of the form, if necessary.
- Proceed to the medical problems section. Indicate if you have any serious medical conditions by marking 'Yes' or 'No' and provide details if applicable. Include any relevant stressors in your life.
- Fill out the daily functioning and self-assessment sections thoroughly. Provide estimates for the time spent on various activities and reflect on your functioning level using the provided scales.
- For the Axis I and Axis II self-report checklists, answer each question with either 'Yes' or 'No' based on your experiences over specified periods. Be honest to help practitioners understand your situation better.
- Finally, review the entire form for completeness and accuracy. Once confirmed, you can choose to save changes, download, print, or share the form as required.
Complete the psychotherapy research program form online to take your first step towards therapeutic support.
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