Progress Note 2022

Psychiatry & Psychology
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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. [select name="variable_229" value="He|She"] was alert and oriented x4 and there were no observed abnormalities or disturbances that would prevent the client from effective engagement and functioning. Self-reported mood was [checklist name="variable_302" value="normal|euthymic|anxious|depressed|angry|euphoric|elevated|dysthymic"]. Participation level and quality was
[checklist name="variable_301" value="active|variable|only responsive|minimal|withdrawn|interactive with supportive prompts|motivated|engaged|forthcoming|attentive|intrusive|monopolizing|resistant"]. Observed affect is within normal range of emotional expressivity and is congruent to client's described mood.

Evaluation of Progress Since Last Session
General Sense of Wellbeing: [select name="variable_776" value="very low, 1|low, 2|average, 3|high, 4|very high, 5"] out of 5
Client reported that [select name="variable_221" value="his|her"] general sense of wellbeing [checkbox name="variable_901" value="is better|is worse|remains high|remains low"] since last session. [textarea name="variable_672" default=""]

Symptom Distress:
[select name="variable_776" value="very high, 1|high, 2|average, 3|low, 4|very low, 5"] out of 5
Client reported that [select name="variable_221" value="his|her"] symptom distress [checkbox name="variable_901" value="is better|is worse|remains high|remains low"] since last session. [textarea name="variable_671" default=""]

Self-reported
[select name="variable_817" value="problems or symptoms of distress since last session including:|denial of any significant problems or symptoms of distress since last session"].

Client reported [select name="variable_300" value= "experiencing the following symptoms|that [select name="variable_221" value="his|her"] mental health is stable and that [select name="variable_228" value="he|she"] denied experiencing symptoms of concern|that [select name="variable_221" value="his|her"] mental health is stable and that [select name="variable_228" value="he|she"] denied experiencing symptoms of concern"]. [checkbox name="variable_302" 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"]
and that these symptoms or problems [checkbox name="variable_306" value= "were rarely experienced|were occasionally experienced|were experienced several times|were experienced often|were experienced very often or constantly"] and experienced to a [checkbox name="variable_307" value= "mild degree|were experienced several times|were experienced often|were experienced very often or constantly"] and caused [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"].

Deviance [select name="variable_79" value="is low or none; symptoms are common related to context and do not appear pathological|is moderate; symptoms are less common related to context and may indicate pathology|is high; symptoms are uncommon related to context and likely indicate pathology"].
Distress [select name="variable_80" value="is low or none|is moderate|is high"].
Dysfunction [select name="variable_81" value="is low or none|is moderate|is high"].
Danger [select name="variable_81" value="is low or none|is moderate|is high"]. There is no current evidence or information to indicate that client is a safety risk to self or others at this time.
[textarea name="variable_200" default=""]

[select name="variable_313" value="No other updates reported|Client reported the following"] updates since last session: [textarea name="variable_199" default=""]

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="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/strategies/techniques/theories introduced this 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.
[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"]

Client Assignment: [text name="variable_53" default=""].

Signed By: Stacey Sugar, MS, LCPC, LPCC
Date: [date name="variable_311" default="date"]
Client Name:
Session Date:
Session Start Time & End Time:
Session Duration: 45 minutes
Session Frequency:
Session Format:
Client Physical Location at Time of Session:
Type of Contact:
Type of Service: Individual Teletherapy
Present During Session:

Client Assessment
Client presented on time for regularly scheduled teletherapy session. was alert and oriented x4 and there were no observed abnormalities or disturbances that would prevent the client from effective engagement and functioning. Self-reported mood was . Participation level and quality was
. Observed affect is within normal range of emotional expressivity and is congruent to client's described mood.

Evaluation of Progress Since Last Session
General Sense of Wellbeing: out of 5
Client reported that general sense of wellbeing since last session.

Symptom Distress:
out of 5
Client reported that symptom distress since last session.

Self-reported
.

Client reported mental health is stable and that denied experiencing symptoms of concern|that mental health is stable and that denied experiencing symptoms of concern"].
and that these symptoms or problems and experienced to a and caused .

Deviance .
Distress .
Dysfunction .
Danger . There is no current evidence or information to indicate that client is a safety risk to self or others at this time.


updates since last session:

Session Content
The therapeutic process was focused on


The main therapeutic interventions included .



Psychoeducation/strategies/techniques/theories introduced this session:

Client Response
Client gained awareness that
.

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.


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.


Client Assignment: .

Signed By: Stacey Sugar, MS, LCPC, LPCC
Date:

Result - Copy and paste this output:

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