Progress Note

First Name: [text name="FirstName" default=""]
Last Name: [text name="LastName" default=""]
Date of Appointment: [date name="DateofAppointment" default="01-26-2023"]
Date Progress Note Completed: [date name="DateNoteCompleted" default="01-26-2023"]
Session Start Time: [text name="SessionStartTime" default=""]EST
Session End Time: [text name="SessionEndTime" default=""]EST

Active Symptoms/Impairments:
Client reported the following symptoms/impairments:
[checkbox name="ActiveSymptomsImpairments" value="Anxious mood|Depressed mood|Obsessive thoughts|Compulsive behaviors|Suicidal ideation|Self harm|Difficulty concentrating|Relationship concerns|Interpersonal ineffectiveness|Difficulty planning/completing tasks|Feelings of overwhelm|Self worth|Avoidant behaviors|Emotion dysregulation"].

Safety and Medical Issues:
Safety Issues: [checkbox name="safetyissues" value="None reported/no risk|Suicidal ideation|Homicidal ideation|Self harming behaviors"]
Client has: [checkbox name="risklevel" value="No intent or plan |Intent to act|Plan to act|Means to act"]

Medication Change: [checkbox name="Meds" value="Yes|No|No report from client|Not on Medication"]
[text name="medchanges" default=""]

Subjective report: 
Client reported [checkbox name="Clientsubjective" value="Feeling depressed|Feeling overwhelmed|Feeling anxious|Lack of motivation|Issues with partner|Issues at work|Anger issues|Mood swings|Feelings of grief and loss|Feeling stressed|Sleep issues|Still feeling stuck|Lack of focus|Defeating self-talk|Difficulty breaking patterns|Feeling better overall|Maintaining progress|Improved communication|Getting more exercise|Better self care|Better work/home life balance|More self-confident|Increase in motivation|Mood swings better"]
[text name="ctreport" default=""].

Ct's location was verified and they were in their [checkbox name="location" value="residence|campus housing|place of employment"] in Georgia for the duration of the visit.

Observations: 
Affect:[checkbox name="affect" value="WNL|Blunted|Flat|Agitated|Hostile|Labile|Restricted|Expansive|Congruent|Incongruent"]
Mood:[checkbox name="mood" value="Elated|Dysthymic|Euthymic|Apathetic|Depressed|Irritable|Anxious"]
Interpersonal:[checkbox name="interpersonal" value="Interactive|Guarded|Withdrawn|Oppositional|Resistant|Defensive|Candid|Cooperative"]
Functional Status:[checkbox name="functioning" value="Minimal|Mild|Moderate|Severe|Variable"]

Ct displayed [checkbox="dress" value="appropriate|disheveled|unusual"] dress and [checkbox name="hygiene" value="adequate|poor"] hygiene. Ct maintained [checkbox name="eyecontact" value="normal|minimal|intense|variable"] levels of eye contact and speech was [checkbox name="speech" value="within normal limits in terms of|slow|pressured|fast|loud|soft|weak|strong"] [checkbox name="wnl" value="rate|prosody|tone"]. Ct appeared to be [checkbox name="engagement" value="engaged|disengaged|unfocused"] in the session, as they [checkbox="responsiveness" value="provided responses to questions asked and remained on topic|were minimally responsive|had difficulty staying on topic|looked away often"]. 

Session Focus: 
This session, the focus was on helping the client [checkbox name="sessionfocus" value="process|manage|evaluate|explore|address|determine|problem solve|cope with"] concerns related to [checkbox name="concerns" value="ongoing stressors|grief and loss|work stress|relationship stress|low motivation|depressed mood|anxiety|low self worth|trauma|feeling overwhelmed|finding a new job|divorce|separation|relationship ending|moving to a new city|starting a new job|managing relationships|time management|financial stress"][text name="other2" default=""].

The following interventions were utilized:
[checkbox name="support" value="The client was supported as they described"][text name="issues" default=""].
[checkbox name="reinforced" value="The client was reinforced for"][text name="progress" default=""].
[checkbox name="validate" value="The client's emotions were validated and explored for cognitive distortions"]
[checkbox name="reframe" value="Negative/distorted thinking was examined and challenged in terms of its accuracy and helpfulness"]
[checkbox name="problemsolve" value="The client was assisted in problem solving"][text name="issue1" default=""][text name="issue2" default=""][text name="issue3" default=""]
[text name="intervention1" default=""][text name="intervention2" default=""].

[checkbox name="HW" value="HW was assigned and included "][checkbox name="assignedHW" value="setting aside time for worry|mindfulness practices|asking for help/support from others|walking/exercising|behavior changes:"][text name="behavchange1" default=""][text name="behavchange2" default=""]
[checkbox name="addlHW" value="catching and reframing negative thoughts|utilizing coping strategies discussed in session|practicing radical acceptance|initiating activities with others|engaging in art/hobbies|maintaining boundaries|developing and enforcing boundaries|communicating feelings with others|drinking less alcohol|journaling|writing a letter|practicing saying 'no'|Saying 'yes' to invitations from others|watching funny/uplifting videos"][text name="otherHW" default=""].

Assessment of Progress:
[checkbox name="progress" value="Client appears to be making progress and reports decrease in|Client has maintained gains since our most recent session including|Client appears to be decompensating based on"][text name="progress1" default=""][text name="progress2" default=""][text name="progress3" default=""][checkbox name="stressors_" value="Client continues to experience stressors including"][text name="stressor1" default=""][text name="stressor2" default=""][text name="stressor3" default=""][checkbox name="sxsevfreq" value="Ct's symptoms have increased in severity and/or frequency and appear to meet the criteria for"][text name="diagnosis1" default=""][text name="diagnosis2" default=""].[checkbox name="insightengagement" value="Ct reports continued insight into the nature of symptoms and improved functioning. Client is engaged and participates actively in sessions and completes any homework assigned|Client is minimally engaged in sessions and does not typically follow through with strategies outside of session|Ct appears anxious and withdrawn in sessions and has difficulty processing emotions"]. 

[checkbox name="re" value="However|Likewise|As a result"] client is still endorsing symptoms of [checkbox name="symptomsstillpresent" value="depressed mood|general worry|low motivation|low self worth|sleep difficulties|emotional dysregulation|difficulty coping|feeling overwhelmed|poor concentration|fatigue|panic|restlessness|feeling numb|anhedonia|feelings of isolation|worry about the future|low appetite|overeating|binge eating|negative outlook|issues with planning/priotizing|tearfulness"]
Ct is experiencing [checkbox name="distresslevels" value="minimal|mild|moderate|severe"]levels of distress and impairment based on presentation in session and self identified symptoms and overall functioning. This impaired functioning includes but is not limited to, social, occupational, and personal day to day activities. 

Medical necessity factors influencing length/frequency of sessions include [checkbox name="mednecessity" value="rapport building with client|history of trauma|recent loss|client crisis|time needed to address and contain intense emotions|prevention of escalating to more intensive level of care|nature of therapeutic interventions|addressing new symptoms|addressing re-emerging symptoms"].

Plan:
[checkbox name="plan" value="Ct will contact this clinician for a follow-up session|Ct is no longer in need of sessions.|This will be the final session.|Ct is taking a break from counseling at this time.|Appropriate referrals have been provided.|Follow up session has been scheduled. Plan is to meet on"][date name="followupdate" default="01-30-2023"] for a follow up session. Plan for session is to check on [checkbox name="checkon" value="homework|recent stressors/emotional experiences|and symptom intensity/frequency"]. Will also follow up on [checkbox name="followupon" value="goals set in previous sessions including|activity scheduling|reframing cognitive distortions|mindfulness exercises|self care|spending time with others|prioritizing/time management|setting/maintaining boundaries|making pros and cons list|journaling|modifying eating/exercise habits"][text name="othercheckin" default=""].