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Therapist One-Month Review Questionnaire (Version 3.2)
(Copyright, R. Elliott, 1986, 1988)

Client: __________________
Therapist: _______________
Event fr. Sess.: __________
Review due: ____________

Please review the notes (and tape if you wish) 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 do you think it has been for your client? (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.     Have you noticed any later impacts of this event on your client?   YES   NO   (If yes, please describe briefly:)

 

 

 

(PLEASE COMPLETE THIS PAGE BEFORE GOING ON.) 

4.     Rate the impacts you would now say that this event has had on your client, 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 MY CLIENT HAS...

1 2 3 4 5     1.     Realized something new about self. Client has an insight about self or has understood something new about self. Client has seen a new connection or seen why he/she did or felt something. (Note: There must be a sense of "newness" about self.)

1 2 3 4 5     2.     Realized something new about someone else. Client has an insight about another person; has understood 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 is clearer about feelings, experiences. Client is more in touch with feelings, thoughts, memories or other experiences. Has become more aware of experiences which she/he had been avoiding. What client was really feeling or trying to say has become clearer. (Note: refers to becoming clearer about what client is feeling rather than why client is feeling something.)

1 2 3 4 5     4.     Definition of problems for client to work on. Client has a clearer sense of what he/she needs to change in his/her life or what s/he needs to work toward in therapy; what client's goals are.

1 2 3 4 5     5.     Made Progress towards knowing what to do about problems. Client hase figured out possible ways of coping with a particular situation or problem. Client has made a decision or resolved a conflict about what to do; has got up energy to do something differently.

AS A RESULT OF THIS EVENT, MY CLIENT NOW FEELS...

1 2 3 4 5     6.     That I understand. Client now feels I really understood what he/she was saying then, or what was going on with client during the event, or what client is like as a person generally.

1 2 3 4 5     7.     Supported or encouraged. Client now feels supported, reassured, confirmed, or encouraged by me. Client feels better about self, or started to like self better. Client has come to feel more hopeful about self or future.

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

AS A RESULT OF THIS EVENT, MY CLIENT NOW FEELS...

1 2 3 4 5     8.     Relieved or more comfortable. Client has felt relieved from the uncomfortable or painful feelings involved in the event; or has felt less nervous, depressed, guilty or angry about what we talked about then or in general.

1 2 3 4 5     9.     More involved in therapy or inclined to work harder. Client has become more involved in what s/he needs to do in therapy; client's thinking has been stimulated; client has started working harder. Client has become more hopeful that activities in therapy will help. Client now feels s/he could be more open with me.

1 2 3 4 5     10.   Closer to me. Client has come to feel that we are really working together to help him/her. Client is impressed with me as a person, or has come to trust, like, respect or admire me more. We have overcome a problem between us.

1 2 3 4 5     11.     More bothered by unpleasant thoughts or more likely to push them away. Event has made client think of uncomfortable or painful ideas, memories, or feelings that weren't helpful. It has made client push certain thoughts or feelings away/avoid them.

1 2 3 4 5     12.     Too much pressure or not enough direction. Client has felt too much pressure to do something, either in the therapy session or outside of it. Client has felt abandoned by me or too much left on his/her own.

1 2 3 4 5     13.     I don't understand. Client has felt misunderstood by me; that I just don't or can't understand client or what client is saying. Client feels I misunderstood just during the event, or generally.

1 2 3 4 5     14.     Attacked or that I don't care. Client has felt criticized, judged or put down by me. Client has felt I was cold, bored, or didn't care.

1 2 3 4 5     15.     Confused or Distracted. Client has felt thrown off or side-tracked from some things which were important to him/her. Client has felt confused by what I said or did, or that I have interfered with what he/she was thinking or talking about during the event or generally.

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

AS A RESULT OF THIS EVENT, MY CLIENT NOW FEELS...

1 2 3 4 5     16.     Impatient or doubting value of therapy. Client has felt bored or impatient with the progress of therapy or with having to go over the same old things over and over again. Client has started to feel that 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. Using the information you have, 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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