Appleseed Community Mental Health Center, Inc. Counseling Progress Note (Page 4 of 8) in pdf

BELLEFAIRE JCB

BEHAVIORAL HEALTH COUNSELING

OUTPATIENT TRAUMA FOCUS COGNITIVE BEHAVIORAL THERAPY (TFCBT) PROGRESS NOTE

CASE TYPE:

WRAP TFCBT;

JOP/WRAP TFCBT;

OUTPATIENT TFCBT;

SCHOOL BASED TFCBT

Client Name:

Klinesmith

Client #: Emily

Date of service

3/2/2010

(Last, First)

Staff ID, Name: 5089 Katie, Koncilja, LPC

01:15 PM

02:10 PM

0.92 UNITS

Client Start Time

Client End Time

Billable Time

01:15 PM

02:10 PM

0.92 UNITS

Staff Start Time

Staff End Time

Total Time

Program RU

Location

Modifier

624 BHC

03 School

Other:

F0 F:F w/Client(IP)

ISP GOAL(S) ADDRESSED:

;

Goal 2) Michelle will demonstrate improved coping skills to better manage difficult feelings,

including those surrounding her history of trauma, as evidenced by guardian and school reports of rule compliance and improved scores in the areas of arguing

with others, getting into fights, yelling, screaming, fits of anger, breaking rules, lying, can’t sit still, feeling lonely, having nightmares and breaking the law on her

;

Ohio Scales.

Goal 3) Michelle will improve her communication skills as evidenced by family reports of improved satisfaction in relationship with IP

and improved scores in the areas of arguing, fights, yelling and screaming, fits of anger, breaking rules, lying, feeling lonely and breaking the law on IPs Ohio

;

Scales.

INTERVENTION

PSYCHOEDUCATIONAL: CLIENT

PSYCHOEDUCATIONAL: PARENT

RELAXATION SKILLS

Rationale for completing narrative

AFFECT EXPRESSION

COGNITIVE COPING TECHNIQUES

INVIVO DESENSITIZATION

Feeling Identification

Cognitive positive self talk

Exploration development of self efficacy

Narrative therapy techniques

Identify and correct cognitive distortions

Safety planning

Behavior management techniques

Identify and correct cognitive distortions

Preparation of parent for sharing of narration

Preparation of child for sharing narration with parent using CBT and client centered techniques

Other:

Briefly Describe: Ip stated that she feels alright about starting her trauma narrative. IP stated an understanding of why the trauma

narrative will be used. IP did very well writing out her positive internal traits paragraphs and appears to be getting better with her

impulsivity of crossing things out quickly. As IP was writing her positive traits this worker assisted in the identification of

cognitive distortions and turning negative statements into positive ones.

Progress:

N/A

No Change

Deterioration

Improvement: If Deterioration or Improvement Noted, Briefly

Describe

Significant Life Changes/Events:

N/A

Yes, Explain:

Recommend Modification to ISP:

Yes, refer to MHA Update

Change in Risk to Self or Others:

Yes, refer to

MHA update;

Suicide Assessment;

Duty to Protect

My signature verifies that service occurred as documented on this progress note. I authorize Bellefaire/JCB to bill for the time documented as “billable” above.

________________________________________________________________

________LPC______________

_____3/12/10______________

STAFF SIGNATURE

CREDENTIAL

DATE

________________________________________________________________

__________________________

________________________

SUPERVISOR SIGNATURE (If Applicable)

CREDENTIAL

DATE