General Progress Note Interventions (Textdump)
[comment memo="Build Trust"] [textarea fillable="true"]The objective of today’s therapy session was to establish trust with the client so that they can begin to identify and express feelings associated with ****** Attempts were made to build a level of trust with the client through consistent eye contact, active listening, unconditional positive regard, and warm acceptance The client’s expression of thoughts and feelings during the therapy session was supported empathetically. The therapy session was helpful in building a level of trust with the client. The therapy session was not successful in establishing trust with the client as they remained guarded when discussing their thoughts and feelings about attending school.[/textarea] [comment memo="Teach Relaxation/Guided Imagery"] [textarea fillable="true"]The client was taught relaxation techniques and guided imagery to promote self-regulation skills. The client was taught relaxation techniques and guided imagery tohelp reduce their anxiety and fear about ****** The client reported a positive response to the use of relaxation or guided imagery techniques to help decrease their anxiety and fearfulness; they were encouraged to continue these techniques. The client has failed to consistently use the relaxation or guided imagery techniques and, as a result, has continued to experience anxiety and fearfulness about ******; the conditions contributing to this failure were reviewed and problem-solved.[/textarea] [comment memo="Employ Art Therapy Techniques"] [textarea fillable="true"]Art therapy techniques were employed to help the client express his/her basic needs or emotions/feelings about ******. Art therapy techniques were employed to help the client establish rapport with the therapist. Art therapy techniques were employed to facilitate a closer parent-child relationship. Art therapy techniques helped the client express basic emotions and identify their needs. The client was uncooperative and resistant to engage during the art therapy session The client’s drawings were noted to reflect feelings of (feelings) about % After completing his/her drawings, the client was able to verbalize their feelings about % and the impact that % has had on their life; the feelings were processed.[/textarea] [comment memo="Play Therapeutic Games"] [textarea fillable="true"]“The ***UnGame” (The UnGame Company) and the “Thinking, Feeling, and Doing” game (Gardner; Creative Therapeutics)*** were played with the client to give them opportunities for self-disclosure Opportunities for feeling identification during games were seized to affirm the client’s self-disclosure. It was reflected to the client that they have become more adept at identifying and expressing their emotions.[/textarea] [comment memo="Enhance Ability to Identify Feelings"] [textarea fillable="true"]Feelings charts and cards were used to teach the client how to identify specific feelings. The client was given positive verbal affirmation and reinforcement for identifying specific feelings during the session. The client’s resistance to identifying his/her feelings was confronted, addressed, and resolved. Through the work with feelings charts and cards, the client has developed the ability to identify specific feelings[/textarea] [comment memo="Educate About Feelings Identification"] [textarea fillable="true"]The client was educated in identifying, labeling, and expressing feelings. The client was given a feelings list and then given various scenarios and asked to identify what the individual in the scenario might be feeling. The client was asked to keep a daily feelings journal. The client was encouraged for showing how he/she has become more adept at identifying and expressing his/her emotions.[/textarea] [comment memo="Identify emotional needs"] [textarea fillable="true"]The client was taught basic concepts of how to identify and verbalize his/her emotional needs. Ways to increase the client’s emotional needs being met were explored. The client failed to clearly identify and verbalize his/her emotional needs or how to meet them and was provided with tentative examples in this area.[/textarea] [comment memo="Share emotional needs"] [textarea fillable="true"]A family session was conducted in which the parents and the client exchanged and identified their emotional needs. The client and family were educated in ways to be sensitive to others’ needs and to ask for their own emotional needs to be met. The client and family were supported as they shared their emotional needs. The client and family have not shared their emotional needs and were redirected to do so[/textarea] [comment memo="Teach Appropriate Versus Inappropriate Anger Expressions"] [textarea fillable="true"]The client was helped to identify appropriate and inappropriate ways to express his/her anger about ******. The client was taught mediational and self-control strategies (e.g., relaxation, “stop, listen, think, and act”) to help express anger through appropriate verbalizations and healthy physical outlets. The client was encouraged to utilize active listening skills to delay the impulse or urge to react with anger or physical aggression when upset about ******. The client identified healthy physical outlets for his/her strong feelings of anger and aggressive impulses, and positive feedback was provided. Despite being taught appropriate anger expression, the client continues to use inappropriate means to express his/her anger about ******. [/textarea] [comment memo="Explore Incidents of Abuse"] [textarea fillable="true"]Possible incidents of physical, sexual, or emotional abuse were explored with the client. Appropriate reporting procedures were followed regarding reports of physical, sexual, or emotional abuse. The client was assisted in exploring how being a victim of abuse has affected his/her feelings about self. The client’s denial and resistiveness were explored and resolved so that the client could connect past abuse with present negative feelings about himself/herself.[/textarea] [comment memo="Encourage Parents to Spend Time With Client"] [textarea fillable="true"]The parents were given the directive to spend 10 to 15 minutes of one-on-one time with the client and siblings on a regular or daily basis, in order to identify the client’s need. It was noted that the one-on-one time spent with the parent(s) has helped the client to decrease his/her feelings of ***depression***. The client and parents reported that the one-on-one time spent together has helped to improve the client’s ***anger control***, and they were encouraged to continue this one-to-one time. The client and parents reported that they have spent little time together because of their busy schedules, and a specific time to be together was identified. The client and parents were strongly challenged to spend time together in order to help the client adjust to ******[/textarea] [comment memo="Teach Parents About Monitoring Progress"] [textarea fillable="true"]The parents were taught about how to monitor the child’s progress and incorporate the data into ongoing clinical decision-making. The parents were taught about how to rate the frequency and severity of unwanted behaviors, disruptions in sleep and eating, and measures reflecting the acquisition and generalization of new skills.[/textarea]
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