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    Progress Note Example

    Uploaded by

    Mohamed Hushain
    This document is a progress note from a therapy session. It includes sections to document the client's appearance, speech, mood, behavior, cognitions, current medications, progress, treatment goals, interventions, and the client's response. It also includes spaces to document a referral, homework, and danger.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Progress Note Example

    Uploaded by

    Mohamed Hushain
    287 views1 page
    This document is a progress note from a therapy session. It includes sections to document the client's appearance, speech, mood, behavior, cognitions, current medications, progress, treatment goals, interventions, and the client's response. It also includes spaces to document a referral, homework, and danger.

    Original Description:

    Counselling

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    © © All Rights Reserved

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    This document is a progress note from a therapy session. It includes sections to document the client's appearance, speech, mood, behavior, cognitions, current medications, progress, treatment goals, interventions, and the client's response. It also includes spaces to document a referral, homework, and danger.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    287 views1 page

    Progress Note Example

    Uploaded by

    Mohamed Hushain
    This document is a progress note from a therapy session. It includes sections to document the client's appearance, speech, mood, behavior, cognitions, current medications, progress, treatment goals, interventions, and the client's response. It also includes spaces to document a referral, homework, and danger.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    PROGRESS NOTE

    JANE DOE, MA
    Your Title
    123 Main Street
    Anywhere, OK 10000
    123-456-7890

    CLIENT: _________________________________

    Appearance
    WNL
    Unkempt
    Dirty
    Meticulous
    Speech
    WNL
    Pressured
    Poverty of
    Impaired
    Slow
    Mood/Affect
    WNL
    Flat
    Depressed
    Manic
    Anxious
    Fearful
    Irritable
    Angry
    Labile
    Incongruent

    DATE OF SERVICE: ______________ TIME: ___________

    SERVICES RENDERED
    Initial Evaluation (90791)
    Psychotherapy: 90832/30
    90834 /45
    90837/60
    Family Psychotherapy w/patient (90847)
    Family Psychotherapy w/o patient (90846)
    Multi-Family Psychotherapy (90849)
    Group Psychotherapy (90853)
    Crisis Psychotherapy 90839/60
    +90840 each addl 30
    Other________
    Other________
    Other________

    PROGRESS
    Exceptional
    Steady
    Slow
    Regressing
    Stable
    Maintaining
    Discharge Plan.

    CURRENT MEDS
    Med:
    Dose:
    Med:
    Dose:
    Med:
    Dose:

    Treatment Goal Addressed: ________________________________________________________________


    Additional Client Concerns Today: __________________________________________________________
    _______________________________________________________________________________________
    Interventions: ___________________________________________________________________________
    _______________________________________________________________________________________
    Clients Response to Intervention: ___________________________________________________________
    _______________________________________________________________________________________

    Behavior
    WNL
    Guarded
    Withdrawn
    Defensive
    Oppositional
    Hostile
    Manipulative
    Impaired
    Threatening
    Impulsive
    Tearful
    Tired

    _______________________________________________________________________________________
    Referred To: ____________________________________________________________________________
    Home Work Assigned Today: ______________________________________________________________
    _______________________________________________________________________________________
    Home Work Completed From Last Session? : __________________________________________________
    Danger to Self or Others? : _________________________________________________________________
    If yes, describe danger and intervention: ______________________________________________________

    Cognitions
    WNL
    Loose Assoc.
    Scattered
    Blocked
    Obsessive
    Paranoid
    Psychotic

    _______________________________________________________________________________________
    Additional Comments: ____________________________________________________________________
    _______________________________________________________________________________________
    Rescheduled for: Day:________
    Fee Charged :________

    Date:_______

    Payment:_________

    Time:_______
    Check

    Client will call or email to reschedule

    Cash

    Credit Card

    Therapist Signature: ______________________________ Degree: _____ Title: ___________ Date: _______


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