Wellness Check-in

Reality Attunement Therapy for Individuals and Couples

Oakland City Center
1305 Franklin Street
Suite 319
Oakland, CA 94612

Phone:
415-508-6263

Request Appointment

Client Wellness Check-in

Please use this form as a prompt to briefly retreat from the busyness of life and report on how you have been doing over the past 24 hours.

Name(Required)
First Last
Email(Required)

Within the past 24 hours, please describe one situation in which you felt at peace and relaxed.(Required)
Within the past 24 hours, please describe one situation in which you felt anxious, disregulated and/or emotionally challenged.(Required)
Considering the past 24 hours, please list one thing for which you are particularly grateful.(Required)

Considering the past 24 hours, how pleased are you with your level of self-care (e.g., diet, exercise, sleep, enjoyable activity, meditation, etc.)(Required)

Highly Pleased

Somewhat Pleased

Neither Disappointed Nor Pleased

Somewhat Disappointed

Highly Disappointed
Considering the past 24 hours, how would you evaluate your relationship to drugs, alcohol, and/or other addictive behaviors?(Required)

Highly Pleased

Somewhat Pleased

Neither Disappointed Nor Pleased

Somewhat Disappointed

Highly Disappointed
Overall, if you set an intention for today, do you feel that you lived up to that intention today?
Yes, I feel that I lived up to my intention today.
No, I feel that I did not live up to my intention today.
Would you like to set an intention for tomorrow?

Please add anything else that is coming up for you, or that you think would be helpful to convey prior to our next session.

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