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Progress Note Example

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.

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Mohamed Hushain
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Available Formats
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678 views

Progress Note Example

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.

Uploaded by

Mohamed Hushain
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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: _______


Copyright 2010-2013 www.Christian-Counseling-Online.com

Bill Insurance

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