Session Number

:

TEN-SESSION SUMMARY FORM
Psychotherapy Research Program at HMS
Leigh McCullough, Ph.D. (3/05)

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Session Date:
Axis I:

_______

Axis I:

_______

Axis IIA: _______
Axis IIB: _______

Patient Name/Initials:

Axis IIC: _______

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Axis III:
Axis IV:

Target Problems: (One to three examples)
1) ____________________________________________________________

TP1 Rating:

2) ____________________________________________________________

TP2 Rating:

3) ____________________________________________________________

TP3 Rating:

Core Conflict(s):
1) ____________________________________________________________

CC1 Rating:

2) ____________________________________________________________

CC2 Rating:

3) ____________________________________________________________

CC3 Rating:

4) ____________________________________________________________

CC4 Rating:

Sess.

Date

MAIN THEME(S) OF SESSION

CC

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CC= Core Affective Conflict focused on during session. List predominant affect and rate 1-10. (10= High)

Rate
1-10

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