Daily Client Check In | ctreatmentcenter

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Cornerstone Treatment Center Mental Health Screening

Client

Pediatric (Ages 5-12)

Adolescents (Ages 13-17)

Date

My goal for today?

My coping skills I been practicing?

I have been taking my meds daily? *

Yes

No

Are you sleeping? *

Yes

No

How often? *

More

Less

About the Same

Are you eating? *

Yes

No

How often? *

More

Less

About the Same

Today im feeling?

Anger

Worried

Excited

Silly

Scared

Embarassed

Happy

Sad

Calm

Other

If selected other please explain below:

Are you sad or depressed *

Yes

No

If yes, please rate your feeling (1 is low-8 high)

1

2

3

4

5

6

7

8

Are you having thoughts of suicide or that you be better off dead? *

Yes

No

If yes, please rate your feeling (1 is low-8 high)

1

2

3

4

5

6

7

8

If yes, do you have a plan? *

Yes

No

If yes, please describe?

Are you hearing voices others don't hear? *

Yes

No

Are you seeing things others don't see? *

Yes

No

If yes, please describe?

Have you harmed yourself in the last 24 hours? *

Yes

No

Have you harmed yourself in the last 24 hours? *

Yes

No

If yes, to whom?

Anything, you would like to share with the therapist? *

Yes

No

If yes, please share?

I give consent to Cornerstone Treatment Center to review my response and upload into my client chart.

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