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OUTPATIENT REHABILITATION DEPARTMENT OTHER PATIENT INFORMATION Psychosocial Issues: Has anyone physically harmed you in any way in the past three months? In your home environment, do you feel: Safe
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Begin by understanding the principles of Acceptance and Commitment Therapy (ACT) and the purpose of the form.
02
Set aside a quiet and uninterrupted time to fill out the form.
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Start by writing down your personal values and goals in the designated sections.
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Reflect on any barriers or obstacles that may be preventing you from living in accordance with your values.
05
Identify specific actions or commitments you can make to move towards your values despite these obstacles.
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Review and revise your responses as needed to ensure clarity and alignment with the principles of ACT.
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Sign and date the form to indicate your commitment to following through with the actions outlined.

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Acceptance and Commitment Therapy (ACT) is a type of therapy that helps individuals learn how to accept and effectively deal with their thoughts and feelings.
Acceptance and Commitment Therapy is typically filed by licensed therapists or mental health professionals who have been trained in this specific type of therapy.
Acceptance and Commitment Therapy is filled out by conducting sessions with clients and guiding them through the principles and techniques of ACT.
The purpose of Acceptance and Commitment Therapy is to help individuals create a rich, full, and meaningful life while effectively addressing the challenges and difficulties that come their way.
Information reported on acceptance and commitment therapy includes client demographics, treatment goals, interventions used, progress made, and any relevant assessments conducted.
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