Rock Springs Check-in Form

Instructions

 

The Check-in form can be completed using Adobe software.

 

Please take a few minutes prior to your session to pause and reflect on the past week.

 

Connection & Compassion

The first section invites you to reflect on events, thoughts, and feelings that occurred this past week that promoted connection and compassion with others and yourself. Connection and compassion can be defined by mindfulness, caring acts, and spiritual practices. Please check as many boxes that represent your experiences over the past week.

Energy

For this section, please reflect upon your energy levels over the course of the week. One way to think about your energy is to consider how you woke up and started your days this past week. Were you energized, excited, and ready to take on the day? NOTE: You may select more than one box if your energy varied widely through the past week.

Any change in medications?

Please select yes or no.

Are you taking a daily multivitamin?

Please select yes or no.

Interpersonal Relationships

Defined as your connections to our friends, families, partners, children, or colleagues. Please take a moment to reflect on the quality of those relationships this past week.

The next line has THREE boxes: Appetite, Activity, Exercise

Appetite

Over the past week, would you say your appetite was UP, DOWN, or the SAME?

Activity

Over the past week, would you say your level of ACTIVITY was UP, DOWN, or the SAME?

Exercise

Most of us have an exercise goal in our minds. For some individuals, it is walking 10,000 steps every day. For others it may be running five miles a day, or going to the gym five days each week. Still others may embrace Barre classes, dancing, golfing or some other form of movement. On a scale of 1-10 with 10 being you met your goals, what did you exercise level reach this past week?

 

Healthy Eating Habits 

 

If you were to visit with a Registered Dietitian, they would likely talk with you about three small and balance meals plus two light snacks throughout the day. Many of our clients are following some recipe for their nutrition, whether it be a Paleo, Low Carb, Weight Watchers, Keto, pescetarian, vegetarian, or simply keeping an eye on what you are consuming.

How many days or what percentage of the time did you meet your nutritional goals?

 

Sleep

Sleep plays an important and fundamental role in our mental health and well-being. Reflecting on the past week, rate how well you slept on a scale of 1-10, with 1 being poor and 10 being well. Please also note how many hours on average you slept per sleep cycle.

Writing Prompts

There are four prompts which you are welcome to answer if you have time and feel that they would be useful:

  1. For whom/what are you grateful?

  2. What did you learn that was new for you?

  3. In what ways have you surprised yourself?

  4. Plan a specific act of compassion or kindness for tomorrow.

​© 2017 by Rock Springs Coaching, Caring, and Counseling, Inc.

​404-721-7409

Midtown: 1708 Peachtree St NW #425  Atlanta GA 30309

Northwest: 1640 Powers Ferry Rd SE Bldg 29, Suite 100 Marietta GA 30067

 

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