Session Note
New York Council on Problem Gambling
Client Name:
Session Date:
*
-
Month
-
Day
Year
Date
Provider ID
Client ID
Type of Service:
Individual
Family
Group
DSM V Score
Family member/Significant other
Problem Gambling 1-3 criteria met
312.31 Gambling Disorder
Mild 4-5 criteria met
Moderate 6-7 criteria met
Severe 8-9 criteria met
Episodic
Perisistent
N/A
In early remission
In sustained remission
Progress/ Update: (Narrative)
Progress/ Update:
*
Decline
No Change
Improvement
Progress/Update (Narrative)
Adjustment to Initial Goals
Was this session helpful to you today?
*
Yes
No
Do you believe you are making progress toward your goals?
Yes
No
Comments:
*
Clinician Signature:
*
I hereby attest that the information completed by me in the preceding forms is true and correct
Client's Signature:
Submit
Should be Empty: