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Therapy Note 05-17-10

This document contains a therapy intake and assessment form for a patient. It includes sections for the patient's signature, presenting issues, subjective and objective assessments. The objective assessment addresses the patient's appearance, eye contact, insights, mood, affect and other factors. The form also includes sections for assessment, treatment goals and objectives, interventions, the patient's response, medication side effects and a treatment plan.

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Errata B
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417 views1 page

Therapy Note 05-17-10

This document contains a therapy intake and assessment form for a patient. It includes sections for the patient's signature, presenting issues, subjective and objective assessments. The objective assessment addresses the patient's appearance, eye contact, insights, mood, affect and other factors. The form also includes sections for assessment, treatment goals and objectives, interventions, the patient's response, medication side effects and a treatment plan.

Uploaded by

Errata B
Copyright
© Attribution Non-Commercial (BY-NC)
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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Signature of Patient: _________________________________

(Signature indicates my attendance at therapy)

Presenting Issues: Anger Depressed Mood Drug/Alcohol Social Skills Interpersonal Relations Physical Aggression Verbal Aggression Destruction of Property

Deceitfulness or Theft Serious Rule Violation Oppositional/Defiant Behavior Inattention Hyperactivity Impulsivity Enuresis/Encopresis Abuse/Neglect/Trauma

School performance Problems Family Problems Grief/Loss Irritability/Low Frustration Self-mutilation/Self-injurious Anxiety Adjustment Issues Other _____________________

Subjective: (Key Statement)

Objective: MSE Appearance: Appropriate Unusual

Eye Contact: Direct Infrequent Poor

Insights: Good Limited Poor

Participation in Treatment: Above Average Average Below Average Well Below Average Mood: Appropriate/Normal Dysthymic Manic

Attitude: Cooperative Resistant Hostile Other Affect: Appropriate Tearful Angry Flat Inappropriate

Speech: Normal Rapid Stuttering Other Psychomotor Activity: Within normal limits Lethargic Restless Agitated Memory: Not tested

Orientation: Person Place Time Situation Attention/Concentration: Appropriate Unusual Impaired Normal

Impaired (Explain)

Thought Processes: Loose Associations Poor No If yes explain

Intact Logical Paranoid Ideation Circumstantial/Tangential Other

Judgement:

Within Normal limits

High Risk Behaviors: ASSESSMENT: Treatment Goal Addressed: Treatment Goal Addressed: Objective Addressed Objective Addressed Intervention and/or Teaching:

Yes

Patients Response:

Side Effects of Medication:______________________________________________________ Plan: Progress Meeting Goals: (slow) 1 2 3 4 5 (Optimal) Continue with current treatment plan If No Explain:
Care Coordination Communication _____________________________________________________________________________________________

Yes

No

Signature of Provider:

Date_________________________

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