Templates/Examples / Posted 6 months ago / 350 views
Client arrived on time to scheduled appointment.
Client did not arrive on time to scheduled appointment, client was –minutes late.
Client did not present with signs or symptoms of suicidal ideation or homicidal ideation, no safety plan is warranted at this time.
Client was cooperative and provided needed information to complete
Client called to reschedule appointment
Completed self-response inventories to gauge client’s symptoms of
Started mental health evaluation for immigration petition.
Reviewed treatment plan with client; client made suggestions, treatment plan will be updated.
Client reviewed and accepted treatment plan.
Clinician was asked to come into session for crisis management by
..indicated client was demonstrating signs of distress as evidenced byProgress Note Phrases
Acknowledged attempts to
Actively listened to client as
Addressed clients concerns
Aided in developing insight
Allowed client to ventilate
Assisted client in/with
Attempted to generalize
Built rapport by
Built trust through
Connect comments about
Developed a contingency plan
Developed behavioral program
Developed positive affirmations
Discussed current stressors and their affect on client’s daily functioning.
Discussed patterns of
Engaged client in play
Established connections between
Explored self-defeating life patterns and beliefs
Helped client develop
Helped client to express anger constructively
Helped client redefine
Led client in practicing
Normalized clients feelings
Provided a corrective social experience
Provided client with unconditional positive regard
Provided psychoeducational information regarding
Reviewed events from previous week
Taught coping skills
Titrated exposure to traumatic events to avoid re-traumatization
Used directive comments to
Utilized assertiveness training
Utilized relaxation training
Utilized empathic understanding
Validates clients point
Worked on behavioral program
Client reports somatic complaints in the form of
Client is currently working on
Client’s initial complaint of
Client is making progress towards
Client is lacking progress towards
Client has made significant changes to
Client seems to be lacking improvement due to
…as evidenced by
Client dissociated briefly while discussing
Client seemed to have a physiological reaction when discussing
Client disclosed recurrent memories/nightmares of trauma
Client expressed a pattern of
Client expressed concerns
Client has experienced intense distress when discussing
Client is unable to recall certain aspects of traumatic event
Client continues to experience persistent negative beliefs/expectations about self
Client continues to blame self/others for causing traumatic event or resulting consequences.
Client reports loss of interest in previously enjoyable activities.
Client reports feelings of
Client reports reactivity in the form of (irritability, aggression, self-destruction, reckless behavior, hypervigilance, problems with concentration, sleep disturbance)
Client continues to employ –as a defense mechanism in order to avoid
Client continues to make SMART goals for self throughout week
Client continues to make plans for the future
Client continues to avoid making plans for the future
Client was assigned
Client will contact clinician to schedule follow up appointment.
Clinician will contact
Collateral meeting needed with
Continue working on treatment plan and make adjustments prior to finalizing with client.
Follow up with
Follow up at next appointment regarding
Next appointment scheduled for
Prepare for termination/discharge at next session.
Referral made to
Research referrals for
Revision of goals warranted, will review at next session.
Treatment/service goals remain appropriate.
Titrate exposure to traumatic events in order to avoid re-traumatization during mental health evaluation.