Melina behavioral tracking tool. 

Melina Behavioral Change Tracking Worksheet

Daily and episode-based tracking of strength, duration, frequency, triggers, recovery, sleep, medication changes, and functional impact.

Provider: Mark Zauss, LMHC, LPC, CCMHC, NBCC, BC-TMC, ADHD-CCSP, C-DBT, CCTP, C-PD

Double Board Certified Counseling Services, Inc.

Date

Completed by Select… Melina Mother Father Aunt / relative Clinician Other

Primary setting observed Select… Home School With friends Work Relatives' home Community / public Multiple settings

Purpose: This worksheet is designed to help Melina, her family, and treating clinicians including Dr. Sack identify patterns over time. Dr. Sack is the treating physician and this was created to support and clarify her symptoms. It is not intended to assign a diagnosis. A sudden or marked change from Melina's previous baseline should be reviewed in the context of sleep, medications, mood symptoms, stressors, ADHD-related emotional regulation, and other medical or psychiatric factors.

1. Current Medication & Change Log

List all psychiatric and relevant medical medications. Update whenever a dose is started, stopped, increased, or decreased.

Medication	Dosage	Date Started	Last Dose Change	Reason / Target Symptom	Observed Change After Start/Change

Any medication change in the past 14 days? Select… No Yes — started medication Yes — stopped medication Yes — dose increased Yes — dose decreased Yes — more than one change

Medication-change notes

2. Daily Baseline Check

Hours slept last night

How did sleep feel? Select… Normal sleep / rested Could not sleep but wanted to Slept less and felt tired Slept less but did not feel tired Very little/no sleep

Energy level (1–5) Select…1 — Very low2 — Low3 — Typical4 — High5 — Very high

Overall mood (1–5) Select…1 — Very low2 — Low3 — Typical4 — Elevated5 — Very elevated / unusually happy

Irritability (1–5) Select…1 — Minimal2 — Mild3 — Moderate4 — Strong5 — Severe

Anxiety (1–5) Select…1 — Minimal2 — Mild3 — Moderate4 — Strong5 — Severe

Appetite Select… NormalReducedVery lowIncreasedVery increased

Intrusive thoughts (1–5) Select…1 — Minimal2 — Mild3 — Moderate4 — Strong5 — Severe

ADHD/executive-function impact today (1–5) Select…1 — Minimal2 — Mild3 — Moderate4 — Strong5 — Severe

3. Behavioral Change — Strength, Duration & Frequency

Strength: How intense was the behavior?   Duration: How long did it last?   Frequency: How often did it happen today?

Behavior	Strength 1–5	Typical Duration	Frequency Today	Notes / Example
Angry outburst / yelling / verbal escalation	--12345	--Under 15 min15–30 min31–60 min1–3 hoursMore than 3 hours / most of day	--01234+
Physical aggression / pushing / hitting / unsafe contact	--12345	--Under 15 min15–30 min31–60 min1–3 hoursMore than 3 hours / most of day	--01234+
Provoking / bothering / repeatedly engaging others after being asked to stop	--12345	--Under 15 min15–30 min31–60 min1–3 hoursMore than 3 hours / most of day	--01234+
Unusual / silly / disinhibited behavior or facial expressions	--12345	--Under 15 min15–30 min31–60 min1–3 hoursMore than 3 hours / most of day	--01234+
Rapid shift from upset/aggressive to apparently normal	--12345	--Under 15 min15–30 min31–60 min1–3 hoursMore than 3 hours / most of day	--01234+
Impulsive / risky / poorly considered behavior	--12345	--Under 15 min15–30 min31–60 min1–3 hoursMore than 3 hours / most of day	--01234+
Unusually elevated / “too happy” / energized presentation	--12345	--Under 15 min15–30 min31–60 min1–3 hoursMore than 3 hours / most of day	--01234+
Withdrawal / shutting down / refusing interaction	--12345	--Under 15 min15–30 min31–60 min1–3 hoursMore than 3 hours / most of day	--01234+

Total significant outbursts today

Worst behavior strength today (1–5) Select…12345

Longest recovery time Select… Under 15 minutes 15–30 minutes 31–60 minutes 1–3 hours More than 3 hours / most of day

4. Episode Detail

Approximate time

Where did it happen? Select…HomeSchoolFriendsPublicRelative's homeOther

Who was present?

What happened immediately before the behavior?

What did Melina actually do or say?

Episode strength (1–5) Select… 1 — Mild / easily redirected 2 — Noticeable but contained 3 — Moderate disruption 4 — Severe escalation 5 — Extreme / unsafe

Episode duration Select… Under 15 minutes 15–30 minutes 31–60 minutes 1–3 hours More than 3 hours / most of day

Returned to usual baseline? Select… Yes — quicklyYes — graduallyPartiallyNoUnsure

Possible contributors present today

Poor sleep Missed meal / hunger Medication change Family conflict School/social stress Sensory overload ADHD frustration / impulsivity No clear trigger

What helped Melina regulate or recover?

5. Functioning Across Settings

Functioning with family (1–5 impairment) Select…1 — Minimal2 — Mild3 — Moderate4 — Significant5 — Severe

Functioning with friends (1–5 impairment) Select…1 — Minimal2 — Mild3 — Moderate4 — Significant5 — Severe

School/work functioning (1–5 impairment) Select…1 — Minimal2 — Mild3 — Moderate4 — Significant5 — Severe

Was there a noticeable difference between settings? Select… No major difference Much better with friends Much better at school/work Much worse at home Much worse in public Varied throughout the day

Setting/context notes

6. Clinical Pattern Score

This score is for tracking change over time. It is not a diagnostic score.

Strength -- / 5

Duration -- / 5

Frequency -- / 4

Functional Impact -- / 5

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Overall Behavioral Change Index: -- / 5

Click “Calculate Score.”

Clinical attention flag: High-strength physical aggression or extreme/unsafe behavior was endorsed. If there is immediate danger, suicidal behavior, psychosis, several nights with little/no sleep plus marked activation, or inability to maintain safety, contact the treating psychiatrist urgently or seek emergency evaluation.

Brief summary for clinician / family review

Calculate Score Save Progress Restore Saved Progress Download / Save as PDF Copy Summary Reset Form

7. Important Clinical Notes

This form is meant to describe behavior objectively and identify patterns over time. Avoid labeling intent (for example, “manipulative”) when an observable description can be used instead. Record what happened, how intense it was, how long it lasted, how often it occurred, what preceded it, and how quickly Melina returned to baseline.

This worksheet is for psychoeducation and symptom tracking and is not a substitute for medical or psychiatric evaluation. Medication changes should be made only with Melina’s prescribing clinician.

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