Patient Progress Notes
Client Name:
*
First Name
Last Name
Session Date:
*
-
Month
-
Day
Year
Date Picker Icon
Physician:
*
Please Select
Amanda Thomas
Ben Landry
Type of Session:
Please Select
Individual
Couples
Family
Group
Service Code:
100
109
245
305
Presentation Assessment
Client Presentation:
Please Select
Oriented/Alert
Disorganized
Tangential
Preoccupied
Circumstantial
Not Assessed
Affect:
Please Select
Appropriate
Inappropriate
Labile
Constricted
Blunted
flat
Not Assessed
Mood:
Please Select
Euthymic
Depressed
Dysphoric
Anxious
Angry
Euphoric
Stable
Not Assessed
Interpersonal:
Please Select
Interactive
Hyperverbose
Guarded
Withdrawn
Hostile
Functional Status:
Please Select
Intact
Impaired
Progressing
Digressing
Variably Impaired
Not Assessed
Medical Issues
Medication Issues:
Yes
No
Explain:
Subjective / Objective
Subjective Report:
Feels depressed
Feeling anxious
Lack of motivation
Sleeping too little
Sleeping too much
Issues with partner
Feels overwhelmed
Feels directionless
Issues at work
Observations:
Seems depressed
Seems anxious
Lack of motivation
Sleeping too much
Issues with partner
Seems overwhelmed
Seems better overall
Seems worse overall
Seems stressed
Interventions
Interventions:
Symptom Mgt
Somatic Exercises
EMDR
Active Imagination
Dream Exploration
DBT
Mirroring
Homework
Recommendations:
Continue Focus
Change Treatment Goals / Objectives
Increase Frequency of Medication
Decrease Frequency of Medication
Terminate Treatment
Other
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