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Progress Notes
Name: DOB: SessionDate:
Start Time: End Time: Diagnosis:
Participants: Medications:
Danger To: None Self Others Ideation Plan Intent Attempt Other
Status Response to TX Appearance
No change Improvement Cooperative Uninterested Appropriate Inappropriate
Set Back Deteriorating Engaged Combative Disheveled Poor
Judgment Insights Speech
Excellent Good Full Partial Appropriate Slurred
Fair Poor Limited None Rapid Pressured
Mood Behaviour Thought Content
Depressed Anxious Appropriate Hostile Pre Occupied Hallucinations
Irritable Angry Distant/Distracted Agitated Delusion Depersonalized
Elevated Poor Eye Contact False Beliefs Irrelevant Detail
Thought Process Orientation Affect
Circumstantial Loose Person Time Blunt Depressed
Tangential Ideal Flight Place Situation Flat Expansive
Euthymic Dysphoric
Constructed
Therapeutic Interventions
Client Centered Therapy Psychoeducation Systemic Family Therapy EMDR
DBT Positive Psychology Play/Art Therapy Humanistic Therapy
Anger Management Problem Solving Skills Cognitive Restructuring Existential Therapy
Attachment Therapy Solution - Focused Roleplay Grief Processing
Coping Skills Supportive Reflections Communication Training Crisis Intervention
Stress Management Building Support Mindfulness Training Trauma Focused CBT
History of Patient Illness Goals/Objectives
Location:
Duration: 1 Day 2 Days 3 Days Other
Timing: Constant Midnight Other
Associated Symptoms:
Medical Hx:
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Evidence Of Patient Response Intervention Studies Implemented /Session Focus On Theme
Session Content
Future Treatment/Follow up Issues
Assigned Homework
Next Apt. Therapist/Provider Signature: Date:
