CCD Progress Note Generator [Training Mode]

CCD Progress Note Generator [Training Mode]

Warning: This training mode is not HIPAA compliant. Do not enter real client data.
Client Name (Disabled for Training Mode)

First NameLast Name
Client DOB (Disabled for Training Mode)

MonthDayYear
Date
Clinician Name

First NameLast Name
Session Date/Time

MonthDayYear
Date
Hour MinutesAM/PM Option
CPT Code

90837908349083290847+90785Other
Session Duration
Automatically populated when you select CPT Code
Participants

Client onlyClient w/ parent present for addressing client's individual goalsClient and familyOther
Diagnosis
This drop-down menu includes commonly used diagnoses for child practices. This is not a comprehensive list.
Diagnosis Description
Describe the diagnostic criteria that applies to the client.
Session Content
Where did the session occur?

Session occurred in person at therapist's office.Session occurred in person at school.Session occurred in person at client's home.Session occurred as telehealth.Other
Who brought the client to the session?

Mother brought client to session.Father brought client to session.Grandparent brought clientDesignated person brought client to session.Other
How did the client transition into the session?

Client transitioned easily on their own.Client transitioned hesitantly on their own.Client transitioned hesitantly with the prompt of therapist.Client transitioned hesitantly with the prompt of therapist with parent.Other
Describe client's play behaviors
How did the client involve therapist during the session?

Client did not involve the therapist throughout play.Client involved the therapist throughout play.Client involved the therapist intermittently throughout play.Other
Include interactive complexity when using the add-on CPT code 90785 for billing

Due to developmental processing needs, client used play equipment to engage in the therapeutic process.Due to the intensity of the emotional experience (trauma), client used play equipment to engage in the therapeutic process.Due to the need to have distance from emotional content, client used play equipment to engage in the therapeutic process.Other
How did the client transition out of the session?

Client transitioned out easily.Client transitioned out slowly.Client transitioned out reluctantly.Client transitioned out with the prompt of therapist.Limits were set.Other
What intervention did you use during the session?

This therapist facilitated Child-Centered Play Therapy skills and responses.This therapist facilitated Child-Centered Play Therapy skills and responses including tracking and co-regulation to increase development of self.This therapist provided developmental and psychoeducational information to support child’s treatment goals.Other
How did the client respond to the intervention?

Client responded by engaging deeper in play and the relationship.Client responded by using (specific toys/experiences) to express internal thoughts/feelings/emotions.Parent appeared receptive.Parent appeared hesitant.Parent appeared unsure.Other
Assessment
What play themes did you observe?

AbandonmentAggressionAnxietyChaos/InstabilityDependencyGrief/LossHopelessnessIntegrationMasteryNurturingPerfectionismPower/ControlPowerlessnessProtectionRelationshipReparationResiliencyRevengeSafety/SecuritySelf SufficiencySeparationOther
Abundance/Scarcity or Fulfilled/UnfulfilledAccuracy/FlexibilityAdequacy/InadequacyContainment/FreedomEffort/Ease or Success/DefeatGood/BadIndependence/DependanceOrder/Disorder or Organized/DisorganizedPower/PowerlessnessProtection/DangerRestored/BrokenSafe/UnsafeSeen/UnseenSeparation/AttachmentSuccess/Defeat
Progress towards SYMPTOM Objectives

Will address in caregiver sessionOther
Refer to Child-Centered Documentation Growth Objectives list for assessing progress towards Growth Objectives.
Progress towards GROWTH Objectives
Describe firsts and which growth objective shows progress towards
Which secondary interventions did you use during the session?

Facilitated decision makingFacilitated development of sense of selfFacilitated development of therapeutic rapportFacilitated directive play therapy interventionsFacilitated executive function skillsFacilitated experiences of co-regulationFacilitated flexibility and creativityFacilitated independenceFacilitated mindfulness experiencesFacilitated processing and integration experiences of neurodivergenceFacilitated relational reciprocityLimits set to facilitate safetyProvided emotional and relational containmentProvided encouragement and sense of self building statementsProvided perspective takingProvided safety for client to process feelings through play/expressive mediums/symbolismProvided structureProvided validation to demonstrate therapeutic connection and awareness of selfReflected feelings to increase awareness of emotions.Relaxation and/or deep breathingReturned responsibilityRole playStructured problem solvingSupportive reflectionTracked play to increase self-awareness and facilitate the relationshipOther
Plan / Frequency
Clinician Signature
Email (for receiving progress note PDF)
example@example.com
Should be Empty:

CCD Progress Note Generator [Training Mode]

Session Content

Assessment