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Client One Month Review Questionaire

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CLIENT ONE MONTH REVIEW QUESTIONNAIRE (Version 3.2)             Client:__________ 
(Copyright R. Elliott, 1986, 1988) Event fr.             Sess.:__________ Review Due:__________

Please re-read your description of the most helpful event in this earlier session, then complete the following items.

1.         Do you remember this event? YES NO (If yes, go on:)

2.         From the point of view of what has happened since this event, how helpful to you do you now see it as having been? (Place an "X" at the appropriate place on the scale below:)

HINDERING <----------------- Neutral -------------------> HELPFUL
1       2       3       4       5       6       7       8       9
|---+---|---+---|---+---|---+---|---+---|---+---|---+---|---+---|
E       G       M       S               S       M       G       E
X       R       O       L               L       O       R       X
T       E       D       I               I       D       E       T
R       A       E       G               G       E       A       R
E       T       R       H               H       R       T       E
M       L       A       T               T       A       L       M
E       Y       T       L               L       T       Y       E
L               E       Y               Y       E               L
Y               L                               L               Y
                Y                               Y

 

3.         Has this event had any specific later impacts on you? YES NO If yes, please describe these impacts briefly:

 

 

(PLEASE COMPLETE THIS PAGE BEFORE GOING ON.) 

 

4.         Rate the impacts you would now say that this event has had on you, using the following rating scale.

Not at all Slightly Somewhat Pretty much Very much
1 2 3 4 5

AS A RESULT OF THIS EVENT, I NOW HAVE...

1 2 3 4 5     1.     REALIZED SOMETHING NEW ABOUT SELF. I now have an insight about myself or understood something new about me. I now see a new connection or why I do or feel something. (Note: There must be a sense of "newness" about yourself.)

1 2 3 4 5     2.     REALIZED SOMETHING NEW ABOUT SOMEONE ELSE. I now have an insight about another person; I understand something new about someone else or people in general. (There must be a sense of "newness" about someone else.)

1 2 3 4 5     3.     MORE AWARENESS OR AM CLEARER ABOUT FEELINGS, EXPERIENCES. I am now more in touch with my feelings, thoughts, memories or other experiences. I have become more aware of experiences which I had been avoiding. What I was really feeling or trying to say has become clearer. (Note: Refers to becoming clearer about what one is feeling, rather than why one is feeling something.)

1 2 3 4 5     4.     A DEFINITION OF PROBLEMS FOR ME TO WORK ON. I now have a clearer sense of what I need to change in my life or what I need to work toward in therapy; what my goals are.

1 2 3 4 5     5.     MADE PROGRESS TOWARDS KNOWING WHAT TO DO ABOUT PROBLEMS. I have figured out possible ways of coping with a particular situation or problem. I have made a decision or resolved a conflict about what to do; I have got up the energy to do something differently.

AS A RESULT OF THIS EVENT, I NOW FEEL...

1 2 3 4 5     6.     FEEL THERAPIST UNDERSTANDS ME. I now feel my therapist really understood what I say, or what is going on with me at that moment in the session, or what I'm like as a person.

1 2 3 4 5     7.     FEEL SUPPORTED OR ENCOURAGED. I now feel supported, reassured, confirmed or encouraged by my therapist. I have come to feel better about myself, or started to like myself better. I have come to feel more hopeful about myself or my future.

Not at all Slightly Somewhat Pretty much Very much
1 2 3 4 5

AS A RESULT OF THIS EVENT, I NOW FEEL...

1 2 3 4 5     8.     MORE COMFORTABLE. I now feel relieved from uncomfortable or painful feelings; I feel less nervous, depressed, guilty or angry about the things I talked about then or in general.

1 2 3 4 5     9.     MORE INVOLVED IN THERAPY OR WORKING HARDER. I have become more involved in what I have to do in therapy; my thinking has been stimulated; I have started working harder. I have become more hopeful that what I have to do in therapy will help. I have felt I could be more open with my therapist.

1 2 3 4 5     10.     CLOSER TO MY THERAPIST. I have come to feel that my therapist and I are really working together to help me. I am now impressed with my therapist as a person, or have come to trust, like, respect or admire her/him more. We have overcome a problem between us.

1 2 3 4 5     11.     MORE BOTHERED BY UNPLEASANT THOUGHTS OR LIKELY TO PUSH THEM AWAY. It has made me think of uncomfortable or painful ideas, memories, or feelings that weren't helpful. It has made me push certain thoughts or feelings away or avoid them.

1 2 3 4 5     12.     TOO MUCH PRESSURE OR NOT ENOUGH DIRECTION. I have felt too much pressure on me to do something, either in the therapy session or outside of it. I have felt abandoned by my therapist or too much left on my own.

1 2 3 4 5     13.     MY THERAPIST DOESN'T UNDERSTAND ME. I have felt misunderstood; that my therapist just doesn't or can't understand me or what I'm saying. I have felt misunderstood about what I was talking about then, or generally.

1 2 3 4 5     14.     ATTACKED OR THAT MY THERAPIST DOESN'T CARE. I have felt criticized, judged or put down by her/him. I have felt she/he was cold, bored or didn't care about me.

1 2 3 4 5     15.     CONFUSED OR DISTRACTED. I have felt thrown off or side-tracked from the things which were important to me. I have felt confused by what he/she said or did. I have felt that my therapist interfered with what I was thinking or talking about.

Not at all Slightly Somewhat Pretty much Very much
1 2 3 4 5

AS A RESULT OF THIS EVENT I NOW FEEL...

1 2 3 4 5     16.     IMPATIENT OR DOUBTING VALUE OF THERAPY. I have felt bored or impatient with the progress of therapy or with having to go over the same old things over and over again. I have started to feel that my therapy is pointless or not going anywhere.

 

5.         Write the number of the most important impact here:____________

6.         Below are the possible changes you described for this event. Please rate the extent to which each of these changes has taken place; use the following scale:

Not at all Slightly Somewhat Pretty much Very much
1 2 3 4 5

1 2 3 4 5     (1)_____________________________________________

                        _____________________________________________

1 2 3 4 5     (2)_____________________________________________

                        _____________________________________________

1 2 3 4 5     (3)_____________________________________________

                        _____________________________________________

Please check your answer to Question 3 on p. 1; if you described any changes not listed above, please add them and rate them below:

1 2 3 4 5     (4)_____________________________________________

                        _____________________________________________

1 2 3 4 5     (5)_____________________________________________

                        _____________________________________________

 

 

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