Case Progress Note Template
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1Case Progress Note
0000
05/13/2010
Client Name:
Client Number:
Date of Service:
0001
Others Present:
Service Provided: 90801 (Intake)
Session Number:
DSM IV Diagnosis
Axis I:
Axis IV:
Axis II:
Axis III:
GAF:
Current:
Highest:
Treatment Goals
1
Began process of initial intake data collection and diagnostic assessment.
2
Become more self-aware; acquire insight into origin of symptoms.
3
4
5
Current Symptoms and Presentation
Mood:
Substance Abuse:
Anxiety:
Somatic Complaints:
Affect:
Sensorium:
Behaviour:
Appearance:
Problems:
Comments:
Harm to Self / Others:
Risk Assessment:
Treatment Status:
Content(s) & Theme(s) Discussed:
Intervention(s):
Symptoms and Day-to-day Functioning
Assessed current level of functioning
Goals and Objectives
Assessed current level of functioning
Stressors and Symptom Triggers
Psychoeducation about therapeutic process
Background History / Information Gathering
Built rapport / conveyed empathetic understanding
Family of Origin
Insight devp of dynamics/patterns/themes/triggers
Interpersonal Dynamics/ Support/ Functioning
Cognitive reframing (Confronted / Challenged)
Parenting
Analyze Here and Now / (Counter)Transference
Trust / Envelopment vs. Mistrust / Isolation
Problem-solving / Brainstorming / Cost v Benefits
Black and White thinking (Rigid thinking)
Increase tolerance of complexity and ambiguity
Perfectionism
Mindfulness (Awareness of thoughts/feelings/body)
Emotional regulation
Affect mgmt (Appropriateness of emotion)
Stress-mgmt (Exercise, Self-care, Meditation...)
Skills Bldg:
Psychoeducation about:
Informed consent, confidentiality, fees, policies
Medication(s) & Dose:
Med Compliant:
Plan/Collateral Contact: • See client individually 1x/week
_________________________________________________
Therapist:
Form created by Matthew Paymar, M.A., LPCC
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