Session Number: __1 __5 __0 Session Date: Axis I: _______ Axis I: _______ Axis IIA: _______ Axis IIB: _______ Axis IIC: _______ Axis III: TEN-SESSION SUMMARY FORM Psychotherapy Research Program at HMS Leigh McCullough, Ph.D. (3/05) Patient Name/Initials: __________________________________________________ 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 Rate 1-10 __1 __2 __3 __4 __5 __6 __7 __8 __9 _0 CC= Core Affective Conflict focused on during session. List predominant affect and rate 1-10. (10= High)

Affect Phobia Ten Session Outline

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psychology brief psychodynamic therapy

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Page 1: Affect Phobia Ten Session Outline

Session Number: __1 __5 __0 Session Date: Axis I: _______ Axis I: _______ Axis IIA: _______ Axis IIB: _______ Axis IIC: _______ Axis III:

TEN-SESSION SUMMARY FORM

Psychotherapy Research Program at HMS Leigh McCullough, Ph.D. (3/05) Patient Name/Initials: __________________________________________________

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 Rate 1-10

__1

__2

__3

__4

__5

__6

__7

__8

__9

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