Therapy Documentation

SAMPLE

Client Name: Vera Hylee Motivated DOB: 9/22/1982 Session Date:  7/25/20xx  Time:  1600-1700

Client Description:

Manner of dress, physical appearance, illnesses, disabilities, energy level, general self-presentation. 

Dressed in professional attire. Appeared fatigued, dark circles under eyes.

Subjective Complaint:

Presenting problem(s) or issue(s) from the client’s point of view.  What the client says about causes, duration, and seriousness of issue(s).  If the client has more than one concern, rank them based on client’s perception of their importance.

Depression for about 2 months, after she moved from her home town. Adjustment to a new job. She has noticed that she no longer has a social life, and is tending to isolate herself. She has not engaged in any of her usual hobbies since she moved to Texas from Minnesota.

Objective Findings:

Counselor’s observation of the client’s behavior during the session.  Verbal and nonverbal, including eye contact, voice tone and volume, body posture.  Especially note any changes and when they occur (such as a client who becomes restless in discussing a topic or whose face turns red under certain circumstances).  Note discrepancies in behavior. Mental Status Exam.

Client was alert and oriented x3. She was interactive, good eye contact. Soft voice. Her overall mood was mildly depressed, affect was constricted. She denied any thoughts of harm to herself or others. She appeard to have good insight and was receptive to feedback.

Assessment of Progress:

Counselor’s view of the client, beyond what the client said or did.  Continual evaluation of client in terms of emotions, cognitions, and behavior.  Identification of themes and patterns in what client says and does.  Use of developmental (Erikson, social learning theory) or mental health models (DSM-IV).  Include your hypotheses, interpretations, and conceptualization of client.

Client verbally acknowledged what was missing in her life and she talked about the current life situation which contributes to her unhappiness. She moved to the area 4 months ago and left her family/friends behind. She has not developed a social support system. She is learning her new job description with no difficulties and does enjoy her work.

Plans for Next Session:

 Plans for client, not for the counselor.  Short and long-term goals.  How you want to interact with client; what you may plan to respond to in next session with client (follow-up on family issues discussed).  Do you plan to help client focus on thoughts, feelings, or behaviors?  What particular strategy or theoretical approach might you use?  What do you base your plan on? What reading or research do you need to do in preparation?  Practice?  What help do you need from your supervisor?

Urge client to formulate a plan that leads to taking action. Encourage her to initiate and respond to at least one social interaction per week. Recommended that she go online to investigate the San Antonio Adventure Club. Recommended that she obtain a weekly copy of the San Antonio Current. Will assist client in solution-focused interventions.  AXIS I: Adjsutment Disorder with depression, 309.0, AXIS II: V71.09, AXIS III: None, AXIS IV: primary support group, social, employment, AXIS V: 63. Next appointment 8/15/20xx at 1600.

Signature, printed name, and credentials of therapist

 

                               

Remember these things when you write notes:

• Always make sure that the name of the client and the date of the session are on each note.

• Always sign and date the notes.

• Try not to be too wordy. Be as concise as possible, but include relevant information.

• Explain to client (if he/she is not aware) that you will be taking brief notes during the session to help focus on the treatment plan goals and progress.

• Try to make sure that notes are written as close to the time of the session as possible. End the session before the end of the hour (5- 10 min) so that you can write your note.

• Include a diagnostic code from the DSM-IV as well as the GAF score.

• Note any of the following symptoms: anxious, aggitated, angry, bitter, bored, confused, delusional, detached, fearful, forgetful, frustrated, grandiose, hostile, impulsive, irritalbe, irrational, manipulative, paranoid, tearful, withdrawn, tense.

• If there is any suicidal or homicidal ideation, ask about any intentions or plans. Be sure to have a safety plan if needed.

• Other issues to note: Abuse, Academic, Adjustment, Anxiety, Conduct, Defiance, Depression, Domestic Violence, Family Conflict, Grief/Loss, Limits, Mania, OCD, Parenting, Phobias, PTSD, Self-esteem, Self-harm, Sleep, Relationships, Thinking Errors.

• Write down the therapeutic interventions/techniques used in the session: Cognitive-Behavioral, Insight-Oriented, Behavior Modification, Play Therapy, RET, Clarification, Provided Emotional Support, Solution-Focused, Problem-Solving, Parenting,  Role Play, Self-disclosure, Reassurance.

• Notate the client's response to interventions

• Write down any referrals and/or assignments

Erin A. Alexander, LPC-S

Upcoming information on: More on Note-writing and Documentation, Treatment Planning, Interventions, Mental Status Exams, Interviewing techniques, Diagnosing (use of the DSM-IV).