Progress Note 2024 – final draft

Client reported that symptoms are [select name="symptom_changes" value="stable/unchanged|improving|declining/regressing|variable/fluctuating"]

Client reported experiencing [checkbox name="symptoms" value="appetite changes|sleep changes|nightmares|low mood|increased mood|tearfulness|feelings of anxiety|feelings of fear|life stressors|feelings of unnecessary guilt|hopelessness|impulsivity|low energy|low motivation|increased motivation|mood swings|obsessions|intrusive thoughts|compulsions|rumination|perfectionism|racing thoughts|panic symptoms|low self-esteem|interpersonal conflict|feelings of loneliness|low energy|high energy|dissociation"] [text name="other_symptoms" default="" size=200]between sessions.


Client reported experiencing [checkbox name="distress_level" value="no disruption in daily functioning.|a limited disruption in daily functioning.|a moderate disruption in daily functioning.|a major disruption in daily functioning."]

The therapeutic process was focused on [checkbox name="therapeutic_focus" value="academic concerns|vocational concerns|executive functioning|adjusting to change/life transitions|trauma|attachment-related issues|codependency issues|substance use|communication challenges|interpersonal relationship challenges|personal goals|decision-making|eating behaviors|emotional dysregulation|relationship patterns|challenges related to upbringing or family of origin|adverse life experiences|grief/loss/bereavement|identity development|self-esteem|values exploration|life purpose/meaning|mental health symptoms|parenting|phase of life problems|positive changes|self-acceptance|self-compassion|self-defeating behaviors"][text name="variable_1" default="" size=200].

The main therapeutic interventions included [checkbox name="intervention" value="reviewed homework|making the unconscious conscious|connecting past experiences to present behaviors|exploring defense responses|increasing awareness of points of avoidance or resistance|facilitating the creation or discovery of meaning|collaborative introspection/examination|pointing out patterns and repetitions|exploring relationship patterns|processing client's recent experiences of interpersonal conflict|exploration of values|radical acceptance|acceptance of factors outside of client’s control and refocusing onto factors within client’s control|mindfulness of cognitive distortions|challenging cognitive distortions and anxious thoughts|strategies to cope with uncomfortable realities or to adapt to stressors|coaching coping skills|practicing use of coping skills|identifying links between thoughts, feelings, and behaviors|naming emotions and putting feelings into words|cognitive refocusing|cognitive reframing|providing interactive feedback|coaching and practicing social/interactive skills|modeling effective communication skills|assertiveness skills|role-play/behavioral rehearsal|supporting client with structured problem solving|allowing client space to vent thoughts and feelings|assisting client to gain new insight into current problem|attempting to explore and explain linked themes|emphasizing feelings to help client experience them more deeply|examining and challenging maladaptive thinking and behaviors|engaging client in collaborative problem-solving and conflict-resolution|facilitating the expression and acceptance of a range of emotions|guiding client through the examination of unresolved conflicts and significant past events|increasing self-acceptance|confidence-building|building self-efficacy|exploring and identifying patterns|executive functioning skill building|interpreting meanings through use of metaphor|practicing mindfulness skills|coaching mindfulness skills|assisting client to practice cognitive restructuring/reframing|reformulating behaviors in a way not explicitly recognized previously|use of paraphrasing and summarizing to gain clarity about client's experience|using reflection and mirroring skills to heighten the client's awareness of and ability to label emotions|using empathy to focus attention on the client and stimulate self-exploration|normalizing client's experience|validating client’s emotions|providing supportive prompts to stimulate client interaction|building rapport|administration of conducting diagnostic assessment|reviewing client's treatment plan and discussing progress towards goals|providing supportive resources|providing educational resources to help client better understand client’s diagnosis and/or symptoms|recommending additional services|providing community referrals|discharge planning"][text name="other_intervention" default="" size=200][checkbox name="psychoed" value=", and psychoeducation "][conditional field="psychoed" condition="(psychoed).is(', and psychoeducation ')"]on [text name="topic"][/conditional].

Assigned homework for completion next session:  [text name="homework" default=""] 

Outcome assessment of session indicated that [checkbox name="outcome" value="client felt heard, understood, and respected|the therapeutic process focused on the client's primary wants and needs|current therapeutic approach is appropriate|the overall session provided benefit related to the client's wants and needs"].

Continue meeting [select name="frequency" value="weekly|every two weeks|every four weeks|monthly|as needed|2x/week"] and working towards established treatment objectives.[checkbox name="plan" value="Client will practice techniques and strategies learned in session.|Client will notify this clinician if change in safety risk occurs and will follow safety plan in the event of crisis"][textarea name="other_plan" default=""]