Академический Документы
Профессиональный Документы
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Filled out in
session
Initials
ID #
Y
N
(Circle)
Started:
Date____/____/____
Actions
Commi
t
Suicide
Self
Harm
Use
TB
Use
TB
Physica
l
Misery
Sadnes
s
Fear
Shame &
Guilt
Anger
Joy
Lov
e
Self
Harm
Target
Behavior
Target
Behavior
Used
Skills
*
Reinforc
e
0-5
0-5
0-5
0-5
0-5
0-5
0-5
0-5
0-5
0-5
0-5
Y/N
Y/N
Y/N
0-7
Day
of
Week
MON
TUE
WED
THU
FRI
SAT
SUN
IsthedoortoSuicide/selfharmopen?Ifsohow?
*Used Skills
0 = Not thought about or used
1 = Thought about, not used, didnt want to
2 = Thought about, not used, wanted to
3 = Tried but couldnt use them
Session
Coming in
Afte
r
Ability to self-regulate
/ self-control: (0-5)
Session
Coming in
After
Emotions:
Action:
Thoughts:
Mindfulness
Adapted from: Behavioral Research and Training Clinic, University of Washington, NIMH4
Filledoutthisside?___Daily___23x____46x___Once___Insession
2004 -
CheckSkills;Circledaysskillwas
practiced
MON
MON
MON
MON
MON
MON
MON
MON
MON
MON
MON
TUE
TUE
TUE
TUE
TUE
TUE
TUE
TUE
TUE
TUE
TUE
WED
WED
WED
WED
WED
WED
WED
WED
WED
WED
WED
THUR
THUR
THUR
THUR
THUR
THUR
THUR
THUR
THUR
THUR
THUR
FRI
FRI
FRI
FRI
FRI
FRI
FRI
FRI
FRI
FRI
FRI
SAT
SAT
SAT
SAT
SAT
SAT
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SAT
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SUN
SUN
1.WiseMind
2.Observe(urgesurfing,justnotice)
3.Describe(putwordson)
4.Participate(enterintotheexperience)
5.Nonjudgmentally(justthefacts:avoidbad,should,stupid,etc.)
6.Onemindfully(presentmoment)
7.Effectiveness(focusonwhatworks)
8.Figureoutinterpersonalgoalsandpriorities:whichisMOSTimportant?
9.Describe___,Express___,Assert___,Reinforce___(DEAR)
10.Mindful:Brokenrecord___,Ignoreattacks___
11.Appearconfident___,Negotiate___
(MAN)
MON
MON
TUE
TUE
WED
WED
THUR
THUR
FRI
FRI
SAT
SAT
SUN
SUN
12.Gentle___,actInterested___,Validate___,EasyManner___(GIVE)
13.Fair___,noApologies___,Sticktovalues___,beTruthful___(FAST)
MON
MON
MON
MON
MON
TUE
TUE
TUE
TUE
TUE
WED
WED
WED
WED
WED
THUR
THUR
THUR
THUR
THUR
FRI
FRI
FRI
FRI
FRI
SAT
SAT
SAT
SAT
SAT
SUN
SUN
SUN
SUN
SUN
14.Attendtorelationships
15.Describeemotions(putnamesonthem)
16.Oppositetotheemotionaction
17.Accumulatepositives___,Buildmastery___,Copeahead___(ABC)
18.PhysicaLill____,Eat___,Avoiddrugs___,Sleep___,Exercise___(PLEASE)
MON
MON
TUE
TUE
WED
WED
THUR
THUR
FRI
FRI
SAT
SAT
SUN
SUN
19.Temperatureice/heat___,IntenseExercise___,Progressiverelax___(
20.MindfulnessofCurrentEmotion(itisawave,letitcomeandgo)
Distress Tolerance
MON
TUE
WED
THUR
FRI
SAT
SUN
MON
TUE
WED
THUR
FRI
SAT
SUN
MON
TUE
WED
THUR
FRI
SAT
SUN
MON
TUE
WED
THUR
FRI
SAT
SUN
MON
MON
TUE
TUE
WED
WED
THUR
THUR
FRI
FRI
SAT
SAT
SUN
SUN
21.Problemsolve(challengethinking,turnthemind)
22.Activities___,Contribute___,Compare___,changeEmotion___,Pushaway
thoughts___,substituteotherThoughts___,intenseSensations(Distract
withWiseMindACCEPTS)
23.Selfsoothe(thefivesenses)
24.Imagery___,Meaningmaking___,Prayer___,Relaxation___,Onething
inthemoment___,miniVacation___,Encourageyourself___(IMPROVE
themoment)
25.ProsandCons(oftoleratingthedistress)
26.RadicalAcceptance(turnthemind,willingness)