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 # 08301990

Date: September 18, 2020 Time: 3 : 00 am/ pm Session Length: 45 min. 60 min. Other:       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: Couple

Explanatory Notes on Symptoms: reports feelings of sadness when it comes to her family and intimate relationship with Dilan. She reports inability to concentrate and obsessive thought patterns. IP also reports that she sometimes has feelings of tension, worrying and anxiety when it comes to getting things done such as meeting deadlines. IP reports that she often time feel hostile and has displayed compulsive behaviors such as cleaning her house. IP reports uncontrollable anger outburst. IP reports that she often has strange thoughts like when she is in a crowded room, she is always looking for an exit. She reports that she has a phobia to being in closed areas or feeling smothered due to past abusive relationships. However, IP reports having feelings of suicidal ideations in lifetime, but no attempts. IP agreed to a more in-dept psych-evaluation and has signed consent giving consent to release information to Spindletop MHMR here in Beaumont and Family Services for psychotherapy.

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. Utilize calming techniques (muscle relaxation paced breathing, calming imagery) as a strategy for responding to anger feelings when they occur. Identify various stimuli (people, situations, thoughts) that have triggered her anxiety and the thoughts or feelings that have characterized her anxiety responses. Jasmine was also referred to further diagnostic testing for psychitric evaluation to determine if there is a need for medication that will be coupled with psychotherapy.

Client Response/Feedback

Jasmine agreed and signed consent giving consent to release her assessment results information for furher assessing of her mental state. Jasmine stated that she was not expecting these results, but wanted to be as honest as she could and welcomed any further assistance.

Plan

Continue with treatment plan: plan for next session: September 25, 2020

Modify plan:      

Next session: Date: 09/03/2020 Time: 3 : 00 am/ pm

Crisis Issues: No indication of crisis/client denies Crisis assessed/addressed: describe below

Jasmine was given a MSE and Sucidal Risk Exam to assess any iniment danger factors and it was determined according to the MSE and Suicide Risk Exam that Jasmine did not pose an immediate threat to herself or others, however proper referrals were made for further assessing at Spindletop MHMR.

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Clinician’s Signature, License/Intern Status Date

Case Consultation/Supervision Not Applicable

Notes:      

Collateral Contact Not Applicable

Name: Spindletop MHMR Date of Contact: 09/18/2020 Time: 4 : 00 am/ pm

Written release on file: Sent/ Received In court docs Other:      

Notes: Jasmine signed consent for Spindletop MHMR

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Clinician’s Signature, License/Intern Status Date

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Supervisor’s Signature, License Date