Language
English (US)
WEEKLY UPDATE
Kila Hillman, MA, LPCC with Santa Fe Psychology
GENERAL INFO
Progress Note Completed by:
Client Name:
First Name
Last Initial
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Contact Information Update:
Additional People in Session:
Name of Person:
Session Location:
Other Location:
Session Type/Duration:
Other:
SYMPTOMS
Focus of Session:
Problem(s) to address this session.
General Problem List:
Other:
Impact of Symptoms on Important Areas of Life:
Other:
Impact Severity:
MEDICATION
Medication Changes:
Changes:
Medication Effectivity (1=poor, 5=excellent):
HIGH RISK BEHAVIORS
High Risk Behaviors this Past Week:
Explanation:
Self-Mutilation Risk Today:
Violence Risk Today:
Suicidal Risk Today:
Homicidal Risk Today:
THERAPEUTIC INTERVENTIONS & MODALITIES
Oriented to:
AEDP/Intra Relational Emotional Processing Utilized:
Other:
CBT Interventions Utilized:
Other:
General Therapeutic Interventions Utilized:
Other:
Healing in Resonance Approach/Attachment Based Parenting Interventions Utilized:
Other:
Mindfulness Interventions Utilized:
Other:
Object Relations/Parts/Internal Family Systems Emotional Processing Utilized:
Other:
Supportive Interventions Utilized:
Other:
Trauma Resiliency/Brainspotting Emotional Processing Utilized:
Other:
PROGRESS
Progress Addressing, Stabilizing, Managing, & Reducing Symptoms:
Other:
Progress Improving Functioning:
Other:
Progress Avoiding Decompensation:
Other:
Progress Preventing a Higher Level of Care:
Other:
Response to Treatment (1=poor, 5=excellent):
Other:
PLAN FOR TREATMENT
Treatment Goals this Session:
Other:
Treatment Goals next Session:
Other:
Plan of Safety:
Other:
Treatment Plan Change:
Other:
Plan to Achieve Treatment Goals:
Other:
Next Session Scheduled:
Other:
Clinician Signature:
Kila Hillman Sena, MA, LPCC
Clear
Clinician:
Date
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Month
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Date
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FILE UPLOAD
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TERMS OF TREATMENT
SELF-SCHEDULER not HIPPA COMPLIANT & an interception risk - OPT IN/OUT:
TEXT not HIPPA COMPLIANT & an interception risk - OPT IN/OUT:
EMAIL not HIPPA COMPLIANT & an interception risk - OPT IN/OUT:
WEEKLY UPDATE FORM COMPLETED PRIOR OR DURING SESSIONS:
CANCELLATION with 24 HOUR NOTICE (unless sick or an emergency):
SAVE/SUBMIT FORM
Submit
Treatment Goals this Session:
Addressing, stabalizing, managing and reducing symptoms.
Improve Functioning.
Preventing de-compensation.
Preventing referral to a higher level of care.
Client Name:
First:
Last
Plan of Safety to Prevent High Risk Behaviors:
N/A
Coping skills that work for your high risk behaviors
Not being alone
Calling trusted people
Calling therapist
Calling psychiatrist
Calling emergency contacts
Calling a mental health hotline
Calling emergency services
Calling 911
Plan to Achieve Treatment Goals:
Client commitment to treatment
Client using coping skills between
Client doing homework as prescribed
Client following plan for treatment
Next Session Scheduled:
In 1 week.
A second time this week due to client's lack of coping with symptoms.
In 2 weeks.
Will schedule if symptoms return.
Change of Plan for Treatment:
Continue with current line of treatment.
Client feels no additional need for therapy.
Client discontinued treatment.
Other clinician referral.
Psychiatric referral.
Psychiatric testing referral.
Group therapy referral.
12 Step program referral.
Session Topics for Today:
Treatment Goals next Session:
Address, stabalize, manage and reduce symptoms.
Improve functioning.
Prevent de-compensation.
Prevent referral to a higher level of care.
Progress:
Client was able to make excellent progress in addressing, stabalizing, managing and reducing symptoms, improving functioning, avoiding de-compensation and preventing referral to a higher level of care.
Client was able to make good progress in addressing, stabalizing, managing and reducing symptoms, improving functioning, avoiding de-compensation and preventing referral to a higher level of care.
Client was able to make some progress in addressing, stabalizing, managing and reducing symptoms, improving functioning, avoiding de-compensation and preventing referral to a higher level of care.
Client was not able to make further progress.
Client regressed.
Response to Treatment (1 poor, 5 excellent):
1
2
3
4
5
General Therapeutic Interventions Utilized:
N/A
Treatment planning.
Devised safety plan.
Facilitated hospitalization.
Discussed behaviors.
Facilitated identity of feelings.
Facilitated problem solving.
Psycho-education.
Cognitive challenging.
Cognitive reframing.
Taught communication skills.
Taught conflict resolution skills.
Organization skills.
Time management skills.
Limit and boundary setting.
Taught social skills.
Taught relaxation skills.
Taught relational skills.
Taught coping skills.
Facilitated experiential behavior/activity.
Facilitated relational and emotionally focused process.
Experiential role play.
Inmterpersonal process.
Experiencial process.
Taught parenting skills.
Emotional differentiation.
Emotional integration.
Cognitive Behavioral Interventions Utilized:
N/A
Discussed negative schemas of self.
Discussed negative schemas of the future.
Addressed errors in thinking and use of Magnification.
Addressed errors in thinking and use of Minimization.
Addressed errors in thinking and use of Overgeneralization.
Addressed errors in thinking and use of Personalization.
Addressed errors in thinking and use of Arbitrary Interference; drawing conclusions without sufficient evidence.
Addressed errors in thinking and use of Selective Abstraction; details taken out of context and believed while other contexts ignored.
Mindfulness Interventions Utilized:
N/A
Observed the present moment as it is.
Worked on being kind and gentle to self.
Allowed judgments to pass by.
Body relaxation to calm nervous system.
Guided meditation.
Sitting Meditation.
Walking meditation.
Breathing exercise.
Intra-Relational AEDP Interventions Utilized:
N/A
Developed self regulation capacity via shared states of affective resonance between therapist, client, and dissociated self-states (client's various subjective selves (internal subjects) and reflective selves (internal objects) and thier internal attachment relationships).
Increased client’s self reflective and emotional processing abilities via bringing together the visceral felt sense in the body in the here and now with the visual imagery associated with the dissociated self-states (client's various subjective selves (internal subjects) and reflective selves (internal objects) and their internal attachment relationships),with here and now consciousness previously disowned affects/emotional memories.
Differentiation of engrained patterns of intra-psychic conflict via authentic, open, internal dialogue between therapist, client, and dissociated self-states (client's various subjective selves (internal subjects) and reflective selves (internal objects) and their internal attachment relationships).
Integration of identity fragmentation, rewiring the brain, via understanding, compassion, and affirmation of self between therapist, client, and dissociated self-states (client's various subjective selves (internal subjects) and reflective selves (internal objects) and their internal attachment relationships).
Healing in Resonance Approach Interventions Utilized:
N/A
Psychoeducation for parents on the structural necessity for the parents to care for and be in charge of the child in a manner that fosters a more Secure Attachment with the child necessary for the child to surrender to their parenting.
Psychoeducation for parents on how to foster a more Secure Attachment with the child via meeting the child's emotional and developemental needs for child to "Trust of Parent's Care" and "Trust of Parents Control".
Psychoeducation for parents on how to foster a more Secure Attachment with the child via utilizing body language; eye contact, facial expressions, tone of voice, proximity and general body language for child to "Trust of Parent's Care" and "Trust of Parents Control".
Taught parents how to foster the child's "Trust of Care" via attending to child's need for physical care and support.
Taught parents how to foster the child's "Trust of Care" via attending to child's need for emotional care and support.
Taught parents how to foster the child's "Trust of Care" via not allowing them to self soothe when upset.
Taught parents how to foster "Trust of Control" by clearly delineating rules, limits and boundaries.
Taught parents how to foster "Trust of Control" by being in charge in the right way; clear, direct and assertive.
Taught parents difference between assertive and passive parenting, and assertive and aggressive parenting.
Taught parents how to foster child's "Trust of Control" by disciplining via the use of Time In's, Marking Behaviors and Natural Consequences of not listening to directives and accepting limits and boundaries.
Instructed child on what they are and are not entitled to.
Instructed child that they must allow for parents care and parents to be in charge of them.
Instructed child as to how they are to ask or check in with parents for almost everything they want to do.
Instructed the child they are not allowed to act out with their behavior; they can ask a question, share a feeling or make a request.
Instructed child on the natural consequences of not allowing parents to care for them or be in charge of them; they will not get to have or do the things they want.
Discussed child's behaviors from prior week.
Discussed what child needs from parent in order to allow for parenting.
Did experiential excercises to practice behaviors.
Brainspotting Interventions Utilized:
N/A
Psychoeducation on activation and downregulation in the nervous system.
Psychoeducation on use of biolateral music in treatment.
Coping skills to mitigate activation and downregulation.
Developed a resource and correlated Brainspot.
Identified past experience causing symptoms and correlated Brainspot.
Titrated back and forth between resource Brainspot and negative past experience Brainspot to desensitize client to negative past experience.
TRM Interventions Utilized:
N/A
Psychoeducation on activation and downregulation in the nervous system.
Coping skills to mitigate activation and downregulation.
Identified past experience causing symptoms.
Focused on experience in the past and what emotions and sensations they are experiencing now when think about what happened then.
Addressed and or acted out what didn't happen then that they needed for safety.
Object Relations/Parts Work/Internal Family Systems Utilized:
N/A
Internal process where a fragmented part of the self was accessed via feelings, images, sensations, movements, voice or words, and/or an energy.
Focused on the part in order to witness and pay attention to it.
Befriended the part via getting a sense of the part; its age, what its concerns and fears are, what it needs, how it is protecting.
Discovered how the part feels about the adult self.
Discovered how the client's adult self feels about the part and its structural relationship it has with the part.
Discovered other parts that are concerned about this part; how they relate to it, if they are collaborating with it, opposing it, or managing access to it.
Facilitated the adult part of the self developing trust via meeting unmet developmental needs of the part to foster increased attachment with the adult self.
Facilitated a structurally sound relationship between the adult self and the part to foster increased integration.
Areas in your Life Impacted:
daily living
family interactions/involvement
fitness/recreational/leisure activities
household
marriage/intimate relationships
physical health
school
self care
social interactions/involvement
work
Medication Changes:
N/A
no
yes
Medication Changes:
Supportive Interventions Utilized:
N/A
Listened attentively and sympathetically.
Comforted.
Advised.
Encouraged.
Provided an emotional outlet.
Provided an opportunity for client to express and be themselves.
Informed client about their diagnosis.
Provided ideas about coping with and manage symptoms.
Medication Effectivity (1=poor-5=excellent):
N/A
1
2
3
4
5
Severity:
moderate
severe
extreme
Current Symptoms:
abandonment issues
ACOA (Adult Child of Alcoholic)
addictive behavior
aggressive physical behavior
aggressive verbal behavior
alcohol use/abuse
amnesia
anger issues
anhedonia (inability to feel pleasure)
anorexia
anxiety
apathy
auditory hallucinations
binge eating
bulimia
chronic pain
compulsions
compulsive gambling
compulsive sexual behavior
cutting/other self mutilation
decreased appetite
delusions
depersonalization (outside observation of self)
depressed mood
derealization (surroundings appear unreal)
diet pill use/abuse
difficulty w/sleep maintenance
difficulty w/sleep onset
difficulty w/understanding
dissociation (disconnected w/surroundings)
distorted body image
distortion or loss of subjective time
distractibility
dysregulation of menstral cycle
employment problems
encopresis(resisting bowel movements/leakage)
enuresis (bedwetting)
exaggerated startle response
excessive exercise
excessive internet use
excessive sleep
exposure to traumatic event
family of origin concerns
fatigue tiredness
fear
fear of open spaces
feelings of guilt shame
feelings of helplessness
feelings of loneliness
feelings of worthlessness
financial problems
forgetfulness
gender identity issues
grief/loss issues
histrionic (melodramatic)
homicidal thoughts
hyperactivity
hypervigilence
hypomania
illegal drug use/abuse
impulsive spending
increased appetite
indecisiveness
inflated self esteem/grandiosity
insomnia
intense fear of weight gain
intentional food restriction
intrusive thoughts
irritability
laxative abuse
legal problems
low energy
low motivation
low self esteem
malingering
mania
marital/intimate relationship issues
medical issues
medical problems
mood swings
obsessive thoughts
occupational problems
over counter drug use/abuse
overwhelmed
panic attacks
paranoia
parent/child problems
peer relationship problems
perfectionism
phobia
poor self image
postpartum depression
prescription drug abuse
provocative/seductive behavior
psychomotor agitation
psychomotor retardation
racing thoughts
recent significant weight gain
recent significant weight loss
recurrent distressing dreams
recurrent thoughts of death
refusal to maintain normal body weight
restlessness
SAD (seasonal affective disorder)
sad mood
school problems
self induced vomiting
self-neglect/poor hygiene
sense of entitlement
sexual problems
sibling conflict
social isolation
stress
suicidal thoughts
tearfulness
thought blocking (thought/speech cessation)
time management
visual hallucinations
worry
SELF MUTILATION, SUICIDAL IDEATION, ASSAULTIVE BEHAVIORS, OR HOMICIDAL BEHAVIORS:
NOT HAVING HIGH RISK BEHAVIORS
YES, HAVING HIGH RISK BEHAVIORS (complete the rest of this section)
SELF MUTILATING BEHAVIORS:
N/A
LOW RISK-ideation with no plan
MODERATE RISK-ideation with a plan
HIGH RISK-ideation with a plan, intent and means
SUICIDAL BEHAVIORS:
N/A
LOW RISK-ideation with no plan
MODERATE RISK-ideation with a plan
HIGH RISK-ideation with a plan, intent and means
ASSAULTIVE BEHAVIORS:
N/A
LOW RISK-ideation with no plan
MODERATE RISK-ideation with a plan
HIGH RISK-ideation with a plan, intent and means
HOMICIDAL BEHAVIORS:
N/A
LOW RISK-ideation with no plan
MODERATE RISK-ideation with a plan
HIGH RISK-ideation with a plan, intent and means
Session Type/Duration:
90832 Individual (20-44 min)
90847 Family Therapy w/client (45-60 min)
90834 Individual Psychotherapy (45-52 min)
90846 Family Therapy w/out client (45-60 min)
90837 Individual Psychotherapy (53-60+ min)
90791 Assessment (60+ min)
Additional People in Session:
No
Yes
Oriented to:
Person, place and time
Not oriented to person
Not oriented to place
Not oriented to time
Names of Additional People:
Session Location:
Office
Teletherapy
Should be Empty: