CI Session Note

Presenting Problem(s)/Session Goals:
[select name="Participants" value="Client|Client and caregiver/parent|Caregiver/Client |Client and sibling"] presented for this [select name="sessiontype" value="individual |family|parent coaching session "] session to address the    following presenting problem:[checkbox name="PresentingProblem" value="ADHD| gender/sexuality adjustment| attachment issues|anxiety symptoms|depression symptoms | obsesive-compulsive symptoms|processing trauma/adverse experiences| relationship stress| difficulty forming and maintaining positive relationships| grief/loss| stressors| peer conflict| family/sibling conflict| managing intense emotions| communication challenges|symptom management|low frustration tolerance |difficulty managing anger| adjustment disorder"]
[text name="other" memo="other" size="12"]
Session Goal(s):[checkbox name="SessionGoals" value="eliminate self-harm behaviors |eliminate sexualized behaviors |increase self-regulation (affect/emotion and behavior) skills. |decrease/eliminate physical aggression – hitting, kicking, biting, and pushing| decrease fears, worries, and anxiety| decrease obsessive-compulsive behaviors including…| decrease non-compliant behaviors and tantrum behaviors |decrease impulsive behavior |increase frustration tolerance |increase the ability to delay instant gratification |increase ability to sustain attention and complete tasks  |increase the ability to delay instant gratification, wait, and share with others | increase age-appropriate interpersonal skills |increase compliant behavior – the ability to comply with directives from caregivers / parents| increase conflict resolution and problem-solving skills| increase coping skills related to trauma symptoms and functional deficits |increase self-soothing skills |improve ability to make decisions and carry out tasks |improve ability to self-care and improve personal hygiene skills |increase academic functioning and organizational skills."][text name="other1" memo="other" size="12"]

Interventions: Therapist [checkbox name="Intervention" value="conducted well-being check and provided reflective listening as client/client and caregiver shared about events and experiences since last session |provided safe and empowering mediums (play, art, sand play, role play, drama play) in  session  |provided therapeutic activities for the safe release of emotions and to practice self-regulation skills |provided therapeutic activities that allow for the safe release of anger and aggression, practiced self-control, and appropriately expressed anger through pretend play and play activities |provided therapeutic play activities that allow for the safe reenactment of trauma events and provided support to process feelings related to adverse experiences |provided therapeutic activities that assist client in expression of grief and loss engaged client in therapeutic activities to allow for the safe expression of feelings of grief and loss|provided therapeutic play activities to allow client to safely express feelings of self-blame and shame |assisted in learning age-appropriate self-regulation skills| assisted in learning assertiveness and communication skills|assisted client in establishing boundaries|assisted in learning coping mechanisms and practiced skills in pretend play |assisted in learning self-control and anger management skills |assisted in learning to sustain attention and complete tasks |rehearsed and practiced social interaction skills through pretend play/role play |assisted in learning cooperative interaction and effective problem-solving skills|assisted in learning to accept directives and limits from caregivers and authority figures|  introduced and supported client to practice coping strategies|  assisted in learning and practicing self-regulation and desensitizing methods to eliminate fears and anxiety gradually|assisted in learning coping mechanisms and practiced skills taught through role play in pretend play"]
[checkbox name="Intervention2" value="facilitated cognitive-behavioral play therapy to help client identify automatic negative thoughts|supported client in reframing automatic negative thoughts|provided psychoeducation about ____ through|modeling|verbal explanation|a worksheet|a diagram|a book|The therapist and client played a game to increase understanding of social conventions/practice impulse control/ foster executive function skills|modeled boundary setting by|prompted client to use coping strategies to reduce response to triggers during the session|introduced mindfulness exercises to|increase client's present-moment awareness and manage anxious thoughts|increase regulate intense emotions|regulate the client's autonomic nervous system|played a game to help the client|to increase awareness of activated somatic response (Perfection)|to practice executive function skills and  impulse control (logic game)|played a game with client to emphasize multiple solutions to a problem|played a game with client to practice problem-solving skills |supported client in addressing a problem using solutions-focused dialogue|supported client to establish boundaries identified and reinforced strengths|supported client to role-play social scenarios to enhance understanding of social conventions and improve communication skills|encouraged client to incorporate movement to process emotions|used visuals to assist with transitions and organization/expectations for the session/identifying feelings|provided psychoeducation to help caregiver consider how stress influences parenting and child’s behavior.|conducted a check-in with the caregiver by phone/email following the individual session"].

Response to Intervention: Client was[checkbox name="Response" value="was engaged and cooperative|was resistant to participating in session| demonstrated an increased ability to self-regulate feelings and behaviors|accepted guidance and redirection to promote safety and prevent self-harm and injury, exhibited no real or pretend self-harm ideation or self-harm behaviors in session  |exhibited improved self-regulation of impulsivity, frustration tolerance, and anger|accepted limits with 2-3 verbal prompts in session |engaged in therapeutic play activities with the therapist in session. |demonstrated improved ability to accept limits as evidenced by fewer verbal prompts continued to have difficulty accepting limits in session |demonstrates increased ability to delay instant gratification in play activities exhibited improved ability to sustain attention and complete tasks in play activities|demonstrates improved on-task behaviors as evidenced by fewer verbal prompts|exhibited improved problem-solving skills and competency in session activities |demonstrated in/ability to express feelings of grief and loss through play activities|exhibited decreased/feelings of guilt, self-blame, and shame in session|expressed fears and worries regarding past trauma experiences and current events in play|was unable to demonstrate/demonstrated the ability to identify and verbally express feelings regarding…|exhibited some/decreased/increased repetitive and compulsive behaviors in therapeutic play activities exhibits poor interpersonal skills and an inability to play cooperatively in session |exhibits limited positive social skills |exhibited no/decreased/increased instances of physical aggression in play activities |exhibited fewer/reenactments of past trauma experiences in play activities|exhibited no/decreased/increased sexualized behaviors and themes of sexual abuse in session|expressed thoughts and feelings related to family dynamics|was somewhat receptive to|was resistant to psychoeducation/prompts/Therapist's feedback as evidenced by client's rationalizing/avoidance by changing the subject/becoming dysregulated/focusing on negative cognitions|pushed/respected boundaries set by therapist|had restricted/excessive motor movement initially/throughout the sesson/at the end of the session."]

Plan:
Next session on[text name="date" memo="date" size="12"]
Presenting Problem(s)/Session Goals:
presented for this session to address the following presenting problem:
other
Session Goal(s): other

Interventions: Therapist
.

Response to Intervention: Client was

Plan:
Next session ondate

Result - Copy and paste this output:

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