Progress Note (v4)

Therapist met with client for an individual therapy session. Therapist welcomed client into a warm, nurturing environment using unconditional positive regard, congruence and empathy to promote feelings of safety and stability. 
Focus of the session was [checkbox value="building rapport to improve therapeutic relationship|self esteem and empowerment|resilience-building and positive self-talk|processing emotions|exploring emotional and interpersonal patterns|triggers/stressors impacting functioning|processing of traumatic experiences|addressing unhelpful thoughts and behaviors|mindfulness| setting boundaries|cognitive coping and emotional regulation skills|self care|assertive communication|interpersonal issues|building crucial c's|safety planning|identity and self-concept|adjusting to change/life transitions|reducing stress|family dynamic/patterns|building self-awareness and insight|enhancing personal agency|problem-solving and decision-making|symptom management|emotional awareness and expression|conflict resolution|physical health and lifestyle habits|educational challenges" ][text memo="Add't focus" size="-7"]
Therapist engaged client in completing a check in about their week to assess client's current symptoms and functioning. Client reported current symptomology as [select name="symptoms" value="stable|unchanged|better|somewhat better|somewhat worse|worse"]
[comment memo="Client reported..."][text memo="Add't symptoms/improvement" size="-7"]

Client talked with therapist about [text memo="Add't themes" size="-9"]

[comment memo="Interventions Used:"]

[checkbox value="Therapist provided supportive validation and reflective listening, along with aiding client in processing thoughts, emotions and perceptions related to issues at hand and worked to develop more effective solutions/coping.|Therapist utilized circular questioning, reflecting feelings and metacommunication to support client in expressing and exploring their feelings.|Therapist used metacommunication, circular questioning and gentle challenging to help client examine patterns in interpersonal relationships and to promote introspection regarding their emotions, thoughts and behaviors.|Therapist utilized reflection and validation of feelings, encouragement and metacommunication throughout the session to help client gain insight.|The therapist and client participated in therapy activities to facilitate problem solving and interpersonal social skill development including expression of emotions and responses to emotions, as well as the examination of the relational patterns.|The therapist assisted client in progressing toward goals throughout the session by assessing current coping skills and encouraging expression of feelings and adaptation of coping skills, as well as exploring the development of additional ones. The therapist provided activities to strengthen the sensory response systems and self-regulation of the client through employing various therapy modalities and therapy techniques as appropriate.|Therapist used solution focused techniques to help client identify solutions that are effective to improve functioning and overall wellbeing.|Therapist assisted client identifying cognitive distortions and used cognitive restructuring techniques to reframe challenges and difficult feelings to positive outlooks for self.|Therapist and client explored their stressors and frustrations. Therapist validated frustrations and empathized with the experience. Therapist and client explored ways to improve distress/frustration tolerance, including healthy distraction (with pleasurable activities, focusing on others, counting, and tasks/chores), radical acceptance, self-soothing techniques, mindfulness, coping thoughts, and self-affirming thoughts.|Therapist and client practiced assertive communication skills to increase interpersonal effectiveness.|Therapist used MI open/closed ended questions and reflective listening.| Therapist provided psychoeducation.|Therapist and client collaborated on ....|Therapist utilized person-centered counseling skills in order to build the therapeutic relationship. Therapist utilized active listening skills in order to gather information, promote insight and autonomy, convey empathy and understanding, and validate the client's experience.|Therapist and client reviewed creation of treatment plan; client identified areas of concern and goals they would like to work on through therapy|Therapist maintained focus on providing a supportive and responsive relationship with client to foster their ability to cooperate."]
[checkbox name="More_tx" value="Therapist guided client through the examination of unresolved conflicts and significant past events to gain insight.|Therapist and client engaged in collaborative problem-solving and conflict-resolution|Therapist aided client in connecting past experiences to present behaviors|Therapist assisted client in identifying links between thoughts, feelings, and behaviors.|Therapist aided client in regulating and expressing emotions by providing a safe space for ventilation of thoughts and feelings without judgment.|Therapist assisted client on gaining new insight into problem|Therapist and client reviewed client's treatment plan and discussed progress towards goals.|Therapist and client worked on understanding and identifying emotional triggers and reviewed coping strategies client can utilize for emotional regulation.|Therapist provided psychoeducation related to client's symptom presentation.|Therapist introduced the concept of mindfulness to aid in self regulation. Therapist taught client a grounding technique and helped client actively practice these within session. Client responded well towards learning these strategies and was open to incorporating these outside of session.|Therapist and client worked on completing a safety plan to address ongoing suicidal ideation and provide strategies and supports to utilize in managing distress and promoting safety. "][text memo="Add't interventions" size="-8"]
 
[comment memo="Play/Art TX"]
[checkbox name="Playarttx" value="Therapist engaged client in play to encourage positive verbal communication and manage anger.|Therapist utilized Adlerian play therapy interventions to assist in building crucial c of connect to address needs related to attention and relationship building. Therapist joined in play with client providing attunement and positive one on one attention. Therapist tracked behaviors, reflected feelings and provided metacommunication about lifestyle.|Therapist and client worked on facilitating various ways of interacting and engaging that fit client's style of connection while also reinforcing mutual enjoyment, positive social skills, and increased tolerance of frustration and flexibility. Therapist provided positive one-on-one attention throughout the session in the form of reflecting feelings,restating content, and metacommunication.|Therapist engaged client in expressive art activity to foster self-expression, insight, and creativity and promote emotional understanding and release.|Therapist and client participated in an interactive Jenga activity to facilitate trust and rapport building, interpersonal social skill development including expression of emotions and responses to emotions, as well as the examination of interpersonal relationship patterns|Therapist engaged client in a self exploration and identity activity to promote self-concept and understanding of values and beliefs. Therapist and client explored patterns within personal values, traits and roles in client's life and examined ways to incorporate top personal values in everyday decision making.|Therapist provided client with therapeutic play activities to practice problem solving, self-regulation and interpersonal skills.|Therapist used therapeutic limit setting to redirect unsafe behaviors.|Therapist provided sensory soothing play activities to strengthen sensory response systems and self-regulation skills.|Therapist reflected client’s feelings and used encouragement to reinforce self-regulation skills.| Therapist used praise to reinforce client’s positive communication and behaviors."]

[comment memo="Anxiety TX"] 
[checkbox name="Anxiety" value="Therapist prompted client to identify origins of anxiety related fears.|Therapist provided client with information related to cognitive distortions.|Therapist and client discussed thoughts, feelings, and behaviors contributing to anxiety.|Therapist assisted client in identifying and reframing cognitive distortions.|Therapist transitioned session to focus on development of mindfulness skills to address anxiety symptoms.|Theraipst taught client deep breathing techniques to better regulate and manage emotions.|Therapist and client practiced learned skills together in session.|Therapist validated client expression of emotions and praised client participation in session.|Therapist utilized exposure thearpy techniques to reduce avoidance behaviors and increase confidence in anxiety-provoking situations.|Therapist closed session by developing a plan for completion of therapy homework with client."]
 
[comment memo="PTSD/Trauma TX"] 
[checkbox name="trauma" value="Therapist collaborated with client in creation of safety plan.|Therapist reviewed previously learned coping skills with client.|Therapist discussed and taught client about the central nervous system and how it relates to processing trauma.|Therapist discussed and taught client about fight or flight responses in relation to trauma experiences.|Therapist prompted discussion involving self-monitoring of thoughts, feelings, and behaviors and explored how client may utilize this skill outside of therapy to address reported problems and concerns.|Therapist and client discussed and processed experience of triggers.|Therapist helped client recognize their cognitive distortions in reaction to experiences of trauma and assisted client in reframing negative self-talk and beliefs in session.|Therapist reframed client negative self-talk with client in session.|Therapist implemented usage of coping worksheet with client in session.|Therapist and client explored underlying beliefs of self and history of negative thoughts of self.|Therapist assigned client with homework in which client monitors exposure and responses.|Therapist practiced healthy communication skills with client in session.|Therapist encouraged client to explore activities in which client may participate in during periods of mood dysregulation.|Therapist taught client mindfulness skills." ]
 
[comment memo="Client Response:"]
[checkbox name="response" value="Client was actively engaged in session and responded well to interventions offered.|Client was disengaged in therapeutic process and progress is minimal.|Client was somewhat engaged in session and responded somewhat positively to interventions used.|Client was passive in treatment and difficult to engage.|Client was engaged in therapeutic relationship but struggles with active participation and lacking motivation towards change."][text memo="Add't response" size="-5"]