LCSW progress note

Subjective
[textarea]  continues to endorse
 indicated
 explored
 shared
 engaged in
 reports feeling
 discussed pros & cons of
 continues to struggle w/ 
 admits
 agrees
 commented
 stated
 denied
 expressed fears of
 added
 asked [/textarea]

Response to Intervention: [textarea]  copes w
responsive to CBT interventions; DBT skill of "check the facts" chain analysis DEARMAN WiseMind  Practiced grounding  Used Internal Family Systems to explore exiled parts and managers  Addressed executive dysfunction  
 tearful throughout session; incongruent affect smiled/ nervous laughter as we discussed difficult topics. Reported an increase/decrease/ no change in trauma responses. CLient stated that they most often react with figh/flight/freeze/appease response
 disclosed increase in irritability;
 decrease in self care; 
 increase in dissociative symptoms
 decrease in social activities;
 increase in negative thinking
 frequently 
 reports that although... it is insufficient[/textarea] [textarea] responsive to attentive listening, empathic responses & cognitive restructuring techniques
responsive to open-ended questions  
negative self-talk & self-critical internal dialogue continue to ruminate & promote depressive sx & anxiety sx[/textarea] 
[textarea] Denied SI, HI, NSSIB, or AVH. Appearance: Judgment: 
Insight: 
Speech: 
Memory Impairment: None/ Intact
Thought Process: Cohesive /Goal Oriented
Mood: 
Eye contact 
Motor Activity 
Affect:  [/textarea] [textarea] Continues to struggle w/ strongly held schemas/interpersonal conflicts
 Acknowledges intellectual understanding and is still in the process of embodying 
 Receptive to intervention
 Shows motivation to change [/textarea]
[textarea] Demonstrated psychological flexibility; made comments indicating rigid thinking
engaged throughout session
 answered questions w/ one word answers
 appeared
 began having great deal of
 expressed commitment around
 verbalizes feeling some relief in discussing
 identified own triggers [/textarea]
Subjective


Response to Intervention:


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