CLINICAL OUTCOMES in ROUTINE EVALUATION

Site ID *

Client ID *

Sub Codes *

Date therapy commenced *

Number of sessions planned *

Number of sessions attended *

Number of sessions unattended

What type of therapy was undertaken with the client? Other specific

What modality of therapy was undertaken with the client? *

Individual
Group
Family
Marital/Couple

Please tick as many boxes as appropriate

What was the frequency of therapy with the client? *

More than once weekly
Weekly
Less than once weekly
Not at a fixed frequency

Please tick as many boxes as appropriate

Which of the following best describes the ending of therapy? (Unplanned) *

Due to crisis
Due to loss of contact
Client did not wish to continue
Other unplanned ending (specify below)

Please tick as many boxes as appropriate

Other unplanned ending (specify below)

Which of the following best describes the ending of therapy? (Planned) *

Planned from outset
Agreed during therapy
Agreed at end of therapy
Other planned ending (specify below)

Please tick as many boxes as appropriate

Other unplanned ending (specify below)

Other planned ending (specify below) (copy)

Risk

Suicide
Self Harm
Harm to others
Legal/Forensic

Contextual Factors

Motivation
Working Alliance
Psychological Mindedness

Benefits of Therapy

Personal insight/understanding *

Yes
No
Not addressed

Expression of feelings/problems *

Yes
No
Not addressed

Exploration of feelings/problems *

Yes
No
Not addressed

Coping strategies/techniques *

Yes
No
Not addressed

Access to practical help *

Yes
No
Not addressed

Control/planning/decision making *

Yes
No
Not addressed

Subjective well-being *

Yes
No
Not addressed

Symptoms *

Yes
No
Not addressed

Day to day functioning *

Yes
No
Not addressed

Personal relationships *

Yes
No
Not addressed

Has contact with this service resulted in a change of medication? *

Yes
No

If yes, is this change likely to be of benefit to the client? *

Yes
No

Details of change: *

Started
No
Number of months until appointment

Name *

First

Last

E-mail *

Has contact with this service resulted in a change of medication? *

Yes
No
Not Applicable

If yes, is this change likely to be of benefit to the client? *

Yes
No
Not Applicable

Details of change: *

Started
Discontinued
Increased
Modified

Exploration of feelings/problems (copy) *

Yes
No
Not Applicable

Has the client been given a follow-up appointment? *

Yes
No
Not Applicable

Number of months until appointment *

Yes
No
Not Applicable

Fullname *

First

Last

Email *

Clinical Outcomes Routine Evaluation

END OF
THERAPY
FORM V.2

Benefits of Therapy

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Clinical Outcomes Routine Evaluation

END OF THERAPY FORM V.2

Benefits of Therapy

END OF
THERAPY
FORM V.2