Checklist of Changes

Please fill out the form below and, when finished, click the Click to Send Form button at the bottom to send the form to me, or you may open a PDF version of the form here to print, fill out and send it to me.

Please indicate, to the best of your ability, any change you have noticed since your last session within the FIRST 24 HOURS.
The success of your treatment depends on how well you communicate with us, and any increased difficulty or improvement that you have noticed. In the first 15 sessions I will need this form completed in order to work with you or your child for the next session.
If the symptom is not relevant, you can leave it as "Not Applicable".


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