Progress Note 2022
Client Name: [text name="variable_21" default=""] Session Date: [date name="variable_22" default=""] Session Start Time & End Time: [text name="variable_1" default=""] Session Duration: 45 minutes Session Frequency: [checkbox name="variable_34" value="1x/week|2x/month|1x/month"] Session Format: [select name="variable_27" value="In person|Telehealth synchronous video|Telehealth synchronous audio|Telehealth synchronous chat"] Client Physical Location at Time of Session: [checkbox name="variable_888" value="In office|Online|State of Maryland|State of California|Out of State"] Type of Contact: [select name="variable_29" value="New Client, Initial Intake Assessment|Established Client, Ongoing|Established Client, Follow-Up|Discharge Planning|Discharge, Final Session"] Type of Service: Individual Teletherapy Present During Session: [text name="variable_32" default="Client"] Client Assessment Client presented on time for [select name="variable_221" value="his|her"] regularly scheduled teletherapy session. Current Symptoms: Client reported that symptoms are [select name="variable_349999" value="stable|improving|declining or regressing|fluctuating"] [textarea name="variable_1009" default=""] Client reported [checkbox name="variable_15644" value="appetite changes|sleep changes|low mood|tearful|fears|life stressors|guilt|heart racing|hopelessness|impulsivity|low energy|low motivatior|procrastination|nausea|mood swings|obsessions|compulsions|fixations|rumination|perfectionism|numbness/tingling|racing thoughts|risk taking|self-esteem|sweating|social problems|trembling/shaking|withdrawal/isolation|disconnection|low energy|high energy|dissociation|detachment|fatigue|feeling down"] [textarea name="variable_9991" default="Symptoms"] Level of Distress: [checkbox name="variable_901" value="None or low| Moderate|High"] Client reported [checkbox name="variable_308" value= "no disruption in daily functioning|a limited disruption in daily functioning|a moderate disruption in daily fucntioning|a major disruption in daily functioning"] Mental Status and Functioning: [checkbox name="variable_3492" value="Consistent or Not Remarkable|Inconsistent or Remarkable"] [textarea name="variable_519" default="Client was alert and oriented x4 and there were no observed abnormalities or disturbances that would prevent the client from effective engagement and functioning."] Safety Risk: [checkbox name="variable_34988" value="None or low|Ideation with plan|Ideation with plan and intent"] [textarea name="variable_5198" default="There is no current evidence or information to indicate that client is a safety risk to self or others at this time."] Non-SI Self-Harm:[checkbox name="variable_34911" value="None reported|Hx of Non SI SH behaviors|Current Non SI SH behaviors"] [textarea name="variable_19999" default=""] Safety Plan on file: [checkbox name="variable_83492" value="Yes|No"] Current Assessment or Presentation Session Content The therapeutic process was focused on [checkbox name="variable_45" value ="Academic/Vocational Concerns|ADHD|Adjusting to Change/Life Transitions|Abuse/Trauma|Attachment/Codependency Issues|Alcohol and Drug Use|Communication Problems|Continued Growth|Decision-Making|Divorece or Separation|Eating Behaviors|Emotional Dysregulation|Family of Origin Conflict |Grief/Loss/Bereavement|Identity/Self-Awareness Issues|Intimate Relationship Conflict|Life Purpose|Mental Health Symptoms|Parenting|Personal Development|Phase of Life Problems|Positive Changes|Self-Acceptance|Self-Defeating Behaviors|Other"] [textarea name="variable_199" default="Other:"] The main therapeutic interventions included: [checkbox name="variable_46" value="Reviewed homework|Clarification|Interpretation and assumption|Pointing out discrepancies|Making the unconscious conscious|Uncovering hidden meanings underneath the surface of communication|Connecting past experiences to present behaviors|Noting and analyzing defenses|Casting a light on points of avoidance or resistance|Facilitating the creation or discovery of meaning|Collaborative introspection/examination|Pointing out patterns and repetitions and examined conflicts/deficits|Activating and encouraging defenses|Helping to resolve conflict|Strategies to cope with uncomfortable realities or to adapt to stressors|Identifying links between thoughts, feelings, and behaviors|Pointing out affective shifts|Naming emotions and putting feelings into words|Reframing|Free association|Transactional analysis|Use of metaphor|Modeling adaptive behavior|Use of role-play|Praise and encouragement|Problem-solving|Normalizing|Reassurance|Encouraged|Ventilation of thoughts and feelings|Supportive bypassing and redirection|Silence|assisting client to gain new insight into problem|attempting to explore and explain linked themes|connecting the dots between past and present experiences|directing attention to feelings regarded by the client as unacceptable|emphasizing feelings to help client experience them more deeply|engaging client in collaborative problem-solving and conflict-resolution|examining and challenging maladaptive thinking and behaviors|facilitating the expression and acceptance of a range of emotions|guiding client through the examination of unresolved conflicts and significant past events|highlighting discrepancies|identifying and challenging resistance/defenses|implicitly indicating parallels|interactive role-playing to support client to work through different behaviors|interpreting meanings through use of metaphor and assumptions|pointing out cognitive distortions|assisting client to practice cognitive restructuring/reframing|using transactional analysis to strengthen the adult ego state|probing thoughts and feelings for recurring patterns in the client’s unconscious mind|reconstructing memories of childhood|reformulating behaviors in a way not explicitly recognized previously|using active listening to understand the incongruencies and congruences between the client’s feelings and words| using paraphrasing and summarizing to gain clarity about the client's experience|using reflection and mirroring skills to heighten the client's awareness of and ability to label emotions|using empathy to focus attention on the client and stimulate self-exploration|normalizing client's experience|providing a safe environment for client to ventilate without interruption|providing supportive prompts to stimulate client interaction|navigating the client through the use of open and close ended questions|conducting tests/assessments|reviewing client's treatment plan and discussing progress towards goals|recommending ancillary services|providing community referrals|dicharge planning"] [textarea name="variable_197" default="Other:"] [checkbox name="variable_305" value="Acknowledged|Affirmed|Asked about|Built rapport|Challenged|Clarified|Confronted|Discussed|Encouraged|Established boundaries|Explained|Explored|Evaluated|Facilitated|Guided|Informed|Identified|Interpreted|Modeled|Probed|Provided|Questioned|Refocused|Reinforced|Responded to|Recommended|Reviewed|Supported|Utilized|Validated"] Psychoeducation/Skill-building: [text name="variable_191" default=""] Assigned homework for completion next session: [text name="variable_191" default=""] Client Response Client gained awareness that [textarea name="variable_410" default=""] Outcome assessment of session indicated that client felt heard, understood, and respected, that the therapeutic process focused on the client's primary wants and needs, that the therapeutic approach is appropriate, and that the overall session provided benefit related to the client's wants and needs. [checkbox name="variable_1000" value="Verbal agreement on accuracy of interventions|Expression of surprise/epiphany/CEE|Emotional release|Freedom to focus on uncomfortable thoughts, feelings, and behaviors|Ability for introspection and autonomy|Applying new insights and testing out new perspectives and behaviors"] [textarea name="variable_195" default=""] Plan & Recommendations 1) Client will continue session frequency. 2) Client will practice new techniques and strategies learned in session. 3) Client will correspond with therapist with questions/concerns before next session. 4) Client will notify therapist if change in safety risk occurs and will follow safety plan in the event of crisis. [textarea name="variable_309" default="sample text"] Signed By: Stacey Sugar, MS, LCPC, LPCC Date: [date name="variable_3155551" default="date"]
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Sandbox Metrics: Structured Data Index 0.56, 34 form elements, 204 boilerplate words, 5 text boxes, 10 text areas, 2 dates, 13 checkboxes, 4 drop downs, 207 total clicks
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