Individual Progress Note

Individual DBT Therapy Progress Note
[text name="variable_1" default="First Name"][text name="LastName" default="Last Name"]
[date name="DateofSession" default="03-04-2023"]

PURPOSE OF SESSION
[select name="variable_2" value="Intake/Assessment|Orientation|Treatment Planning|Psychotherapy Session"]
WAS DIARY CARD COMPLETED?
[select name="variable_3" value="Yes|No"]
[textarea name="variable_4" default="If diary card completed, what was the agenda items?"]

FIRST STAGE TARGETS: 
[checkbox name="variable_5" value="Decreasing Sucidal Behaviors|Decreasing Therapy-intefering behaviors|Decreasing quality-of-life-interferring behaviors"]

SUICIDAL/PARA-SUICIDAL BEHAVIORS
[text name="variable_1" default="No SI Behaviors |Attempt|Self-harming|Verbalizing SI intent"]

BEHAVIORAL DYSREGULATION:
[checkbox name="variable_7" value="No behavioral issues|Verbal altercations with peers|verbal altercations with staff|Physical aggression|Restrictions|Refusal to participate in daily schedule"]

Weekly Skills Group Topic (Mindfulness, Emotion Regulation, Interpersonal effectiveness, Distress Tolerance):
[textarea name="variable_8" default="Category & Skill"]

INTERVENTIONS UTILIZED
[checkbox name= "Variable_9" value="Actively listened to client discuss current stressors, symptoms, and general functioning|Psychoeducation on nature of depression, characteristic symptoms, diet, sleep, self-esteem, self-image and physical exercise|Psychoeducation on nature of anxiety and panic symptoms the role of avoidance, and the rationale for various interventions|Chain Analysis (Problem, Solution)|Exposure therapy approaches|CBT Interventions used for the exploration of patterns of certain thoughts, feelings and behaviors|Led client in Relaxation Techniques|Led client in Mindfulness Activity|skills review|Assessed and monitored the clients suicide potential|Validated distress and difficulties as understandable given circumstances, thoughts and feelings"]

PARTICIPATION:[comment memo="no concerns-attended well|seemed unaware|inattentive|distractible|hyper-vigilant|scattered concentration|preoccupied|confused|focused on irrelevancies"]
ENGAGEMENT: [comment memo="no concerns-engaged well|avoided eye contact|fixed staring|glaring at author|tense facial expression|dependent and needy|dramatic and exaggerating concerns|passive and difficult to engage|uninterested|silly and joking around|resistant|critical and verbally combative|hostile and threatening|sarcastic and taunting|irritable|fatuous|flirtatious|demanding|threatening|guarded|paranoid|defensive and resistant|manipulative|argumentative"] 
SPEECH: [comment memo="spontaneous|normal RTV|abnormal RTV|clear and articulate|selectively mute|mute|loud|laconic|verbose|quiet|pressured|rambling|babbling|incongruent with mood and current circumstances"]
THINKING: [comment memo="logical|linear|rigid"]
ORIENTATION: [comment memo="no concerns|AH reported|VH reported|poor judgement|poor reality testing|poor insight|complete denial"]

SESSION NARRATIVE:
[textarea name="variable_15" default="Narrative of Session"]

TREATMENT PLAN AND SESSION: 
[textarea name="variable_16" default="Patient Goals and session"]

MENTAL STATUS EXAM:
General:[checkbox name="variable_17" value="alert and oriented in all spheres|obtunded|disoriented"]
Behavior - general:[checkbox name="variable_18" value="in no acute distress|in acute psychological distress"]
Behavior - eye contact:[checkbox name="variable_15" value="eye contact good|eye contact fair|eye contact avoidant"]
Mood/Affect - stated:[checkbox name="variable_16" value="normal|upbeat|euthymic|depressed|anxious|angry|hopeless|labile"]
Mood/Affect - emotional range:
[checkbox name="variable_17" value="normal|broad|restricted|flat]
Mood/Affect - congruence:
[checkbox name="variable_19" value="mood is congruent with affect|mood and affect are not congruent"]
Thought form and content:[checkbox name="variable_20" value="normal|future oriented|logical, linear and goal-oriented|past oriented and somber|goal directed|scattered|hopeful|remorseful|enthusiastic|resigned"]
Attention:[checkbox name="variable_21" value="no difficulty with attention or concentration|had some attentional and concentration problems session"]
Perception - insight:[checkbox name="variable_22" value="normal insight|poor insight"]
Cognition/Memory:[checkbox name="variable_24" value="normal|grossly intact|below average|above average"]
Judgment:[checkbox name="variable_26" value="normal|good|poor|"]
Suicide/Assault:[checkbox name="variable_27" value="no current or past ideation or intent|denies an active sense of wanting to harm self or others|present but without intent or plan|resolved"]
[textarea name="variable_1" default="SI/Additonal Comments"]

Ryan Ayala, MSW, APSW
Unit Therapist
Milwaukee County Children, Youth, and Family Services
Juvenile Detention Facility