Confivent Therapy EHR

Clinical Session Progress and Intake Record

1. Patient Contact & Demographics

Full Name

Email Address

Phone Number

Age

Gender

Chief Complaints

Sleep Hours (per day)

Sleep Schedule (Time of day)

Eating Pattern (Times / day)

Anxiety Level (1 - 10)

1 (Minimal) 5 10 (Severe)

Other Relevant Subjective Data

Notes & Treatment Regimen

Care Plan Elements

Referrals & General Remarks

Total Registered Records

Average Anxiety Level

Unique Client Directory

Date	Name	Age/Gender	Anxiety Level	Chief Complaint	Action

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