Scribd
Upload
173 views

(Client's Self-Report of Problems, Progress) :: Elim Home

The document contains progress notes from a counseling session. It includes sections for symptoms, assessment, and a treatment plan. The client's attitude was cooperative and affect was appropriate. Strengths included insight and accepting feedback, while limitations were distrust and lack of social skills. The treatment plan focused on an unspecified problem, with goals of progress and achieving objectives. The client was referred to outpatient weekly counseling.

Uploaded by

Kymberley Gillespie Andrews
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
173 views

(Client's Self-Report of Problems, Progress) :: Elim Home

The document contains progress notes from a counseling session. It includes sections for symptoms, assessment, and a treatment plan. The client's attitude was cooperative and affect was appropriate. Strengths included insight and accepting feedback, while limitations were distrust and lack of social skills. The treatment plan focused on an unspecified problem, with goals of progress and achieving objectives. The client was referred to outpatient weekly counseling.

Uploaded by

Kymberley Gillespie Andrews
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 1

Progress Notes

Client: Session # Time: 30/45/60/90


Date: Location: Elim Home
S-symptoms, (Client’s self-report of problems, progress): ATTITUDE: Cooperative, Hostile,
Open, Secretive, Evasive, Bored,
1) Suspicious, Apathetic, Easily
distracted, Focused, Defensive.
2) AFFECT: Bright, Blunted, Flat,
Exaggerated, Appropriate or
3) Inappropriate, Stable, Labile
MOOD: happy, sad, despondent,
4) Bible Verse: melancholic, euphoric, elevated,
5) depressed, irritable, anxious, angry,
euthymic

A-assessment, Signature: William B Andrews, Jr


Strengths Limitations Progress Social Motivation Relapse Client URICA Suicidal or Strongholds
Rating Support prognosis Profile Homicidal
Insight Lacks Insight No change POOR LOW POOR HI/LC (PC) Yes Denial
Confident Distrustful Progress FAIR AVG FAIR HI/HC (C) S/H Displacement
Clear Defensive Regression GOOD HIGH GOOD LI/LC (A) No Intellectualization
Thinking Defiant LI/HC (M) Projection
Accepts Lacks Social Drug of Spiritual Approach Spiritual False Belief Attachment Session Rationalization
Feedback Skills Choice foundation Growth Styles Goals/meet Minimization
Expressive/ Impulsive Alcohol Protestant Prophet Chair 1 Failure Secure Yes Regression
Articulate Resistive Cocaine Priest Chair 2 Rejection Avoidant Repression
Catholic
Physically Poor Health Pre-Drugs Cult Chair 3 Punishment Anxious- No Sublimation
Healthy Noncompliant Sex/other Chair 4 Shame ambivalent Suppression
Other
P-plan,(Next Session: Focus of Treatment: Problem: Goal: Objective: Axis I:

Axis II:
Homework, (completed Y/N, NA) ( Assign: Y/N ): Exercise:
GAF:
Recommended level of care: Inpatient, Outpatient intensive; Outpatient weekly; Self care @Home
Referrals: ( education, vocational, counseling, spiritual, housing, medical)
Client: Session # Time: Time:
30/45/60/90
Date: Location: Elim Home
S-symptoms, (Client’s self-report of problems, progress): Focus of Tx: ATTITUDE: Cooperative,
Problem: Hostile, Open, Secretive,
1) Evasive, Bored, Suspicious,
Goal: Apathetic, Easily distracted,
2) Focused, Defensive.
Objective: AFFECT: Bright, Blunted,
3) Flat, Exaggerated, Appropriate
4) Bible Verse:
or Inappropriate, Stable, Labile
MOOD: happy, sad,
5) despondent, melancholic,
euphoric, elevated, depressed,
irritable, anxious, angry,
A-assessment, Signature:_ William B Andrews, Jr._________________________ euthymic

Strengths Limitations Progress Social Motivation Relapse Client URICA Suicidal or Strongholds
Rating Support prognosis Profile Homicidal
Insight Lacks Insight No change POOR LOW POOR HI/LC (PC) Yes Denial
Confident Distrustful Progress FAIR AVG FAIR HI/HC (C) S/H Displacement
Clear Defensive Regression GOOD HIGH GOOD LI/LC (A) No Intellectualization
Thinking Defiant LI/HC (M) Projection
Accepts Lacks Social Drug of Spiritual Approach Spiritual False Belief Attachment Session Rationalization
Feedback Skills Choice foundation Growth Styles Goals/ meet Minimization
Expressive/ Impulsive Alcohol Protestant Prophet Chair 1 Failure Secure Yes Regression
Articulate Resistive Cocaine Priest Chair 2 Rejection Avoidant Repression
Catholic
Physically Poor Health Pre-Drugs Cult Chair 3 Punishment Anxious- No Sublimation
Healthy Noncompliant Sex/other Chair 4 Shame ambivalent Suppression
Other
P-plan,(Next Session: Focus of Treatment: Problem: Goal: Objective: Axis I:

Homework, (completed Y/N,NA) ( Assign: Y/N ) Exercise: Axis II:

GAF:
Recommended level of care: Inpatient, Outpatient intensive; Outpatient weekly; Self care @Home
Referrals: ( education, vocational, counseling, spiritual, housing, medical )

You might also like