Mental Healthcare Checklist

How to access the information on this page:

  1. Directly on this page

2. Mental Health Checklist as a hard copy

3. Mental Health Checklist to download and fill out on your device, making updates anytime

Date: ___________________

Child’s name: _______________________________________________ Date of birth: __________________

Therapist’s name: ____________________________________________ Phone: _______________________

Therapist works for: _________________________________________________________________

Email: _______________________________________________________

Collect Information, Monitor & Report

Review past records or contact previous providers

Obtain family history

Obtain mental health assessments, such as DAF

Obtain diagnosis(es)

Medication Management

Name, address and phone number of current medication provider:

Medication(s) & dosage(s):

Attend medical-somatic (med-som) appointments (appointments with the prescriber)

Invite parent/caregiver to attend med-som appointments

Parent/caregiver attended med-som appointment(s)?

Appointment history:

Treatment(s) & Services

Type(s) of treatment/service received:

Start date:


Treatment Goals:

Progress/Engagement with Therapy:


Additional Service Recommendations:

Anticipated Treatment End: