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Do you sleep well at night?
   
 
 
 
Do you feel the need to be in control?
 
Yes
 
No
 
Other
 
 
 
 
Overall, how would you describe your mood?
 
Great
 
Sad
 
Mad
 
Angry
 
Other
 
 
 
 
What do you see in your patient as you speak with her?
   
 
 
 
What brings you here?
   
 
 
 
What brings you here?
 
Yes
 
No
 
 
 
What is the problem from your viewpoint?
   
 
 
 
What is the problem from your viewpoint?
 
Good
 
Bad
 
Sad
 
Angry
 
Other
 
 
 
 
What makes the problem better?
   
 
 
 
If you could wave a magic wand, what positive changes would you make happen in your life?