Counseling Report

Counselor's Name*
First Last
Email Address*
You will receive a copy of this counseling report for your own records.
Counseling Assistants?*
If you had the assistance of any other counselors, then select "Yes" and add their names below. Use the "+" icon to add more rows for names, if needed.
- No
- Yes
Counseling Assistant Name(s)*
First Last
Report Details
Person's Name*
The name of the individual you met with.
First Last
More than one person in this counseling report?*
If this report is about meeting with more than one person (i.e., a spouse) then select "Yes" and add their names below. Use the "+" icon to add more rows for names, if needed.
- No
- Yes
Others Present*
First Last
Meeting Date*
MM slash DD slash YYYY
Meeting Place*
Meeting Notes*
Do you have another meeting set up?*
A follow-up meeting, or another necessary meeting coming out of this counseling session.
- Yes
- No
- Not needed
Next Meeting Date*
MM slash DD slash YYYY

Report Details

First	Last

First	Last