This is the final written assignment in this course. Throughout the course, you should work to infuse information about your couple and identified patient (Jasmine) in each section. This template is
Progress Note for Client # 083090
Date: 08/24/2020 Time: 3 : 00 am/ pm Session Length: 45 min. 60 min. Other: 90 minutes
Present: Adult Male Adult Female Child Male Child Female Other:
Billing Code: 90791 (eval) 90834 (45 min. therapy) 90837 (60 min. therapy) 90847 (family) Other:
Symptom(s) | Duration and Frequency Since Last Visit | Progress |
1: Irritability | 6 months | |
2: feelings of worry | 3 months | |
3: restlessness | 3 months |
Explanatory Notes on Symptoms: This was the couples initial session and therefore no issues were addressed but was identified
In-Session Interventions and Assigned Homework
look at her negative thinking patterns that have contributed to her anxiety and replacing them with more positive and realistic thoughts by having her to identify those thinking errors and coming up with more rational interpretations. They were given the Gottman's Love Map Questionaire and received detailed feedback on their responses.
Client Response/Feedback
Both agreed after completing the questionaire that they were not ready to get married and agreed that they needed to learn more about each and build a solid foundation and therefore this sessions focussed was shifted to couples instead of pre-martial.
Plan
Continue with treatment plan: plan for next session:
Modify plan: Plan was modified after formal assessment and the approach will be couples counseling
Next session: Date: 09/09/2020 Time: 3 : 00 am/ pm
Crisis Issues: No indication of crisis/client denies Crisis assessed/addressed: describe below
________________________________, _________________ ________
Clinician’s Signature, License/Intern Status Date
Case Consultation/Supervision Not Applicable
Notes:
Collateral Contact Not Applicable
Name: Date of Contact: Time: : am/ pm
Written release on file: Sent/ Received In court docs Other:
Notes:
________________________________, _________________ ________
Clinician’s Signature, License/Intern Status Date
________________________________, _________________ ________
Supervisor’s Signature, License Date
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