K2S PROGRESS NOTE
Unique ID
First Name
Last Name
DOB
Unique ID
Today's Date
Time
Service Type
Individual 45 minutes (90834)
Family w/ client 45 minutes (90847)
Family w/out client 45 minutes (90846)
Diagnosis 1
ADJUSTMENT DISORDER (MIXED DISTURBANCE CONDUCT & EMOTION)
ADJUSTMENT DISORDER (MIXED DISTURBANCE EMOTION
ANXIETY DISORDER
PTSD
OCD
DEPRESSIVE DISORDER
PTSD
ADD
ADHD
CONDUCT DISORDER
ODD
EXPLOSIVE ANGER DISORDER
GRIEF/LOSS
Diagnosis 2
ADJUSTMENT DISORDER (MIXED DISTURBANCE CONDUCT & EMOTION)
ADJUSTMENT DISORDER (MIXED DISTURBANCE EMOTION
ANXIETY DISORDER
PTSD
OCD
DEPRESSIVE DISORDER
PTSD
ADD
ADHD
CONDUCT DISORDER
ODD
EXPLOSIVE ANGER DISORDER
GRIEF/LOSS
Diagnosis 3
ADJUSTMENT DISORDER (MIXED DISTURBANCE CONDUCT & EMOTION)
ADJUSTMENT DISORDER (MIXED DISTURBANCE EMOTION
ANXIETY DISORDER
PTSD
OCD
DEPRESSIVE DISORDER
PTSD
ADD
ADHD
CONDUCT DISORDER
ODD
EXPLOSIVE ANGER DISORDER
GRIEF/LOSS
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Mental Status
Client Presentation
Oriented/Alert
Disorganized
Tangential
Preoccupied
Circumstantial
Not Assessed
Functional Status
Interactive
Hyperverbose
Guarded
Withdrawn
Hostile
Mood
Within Normal Limits
Euthymic
Depressed
Dysphoric
Anxious
Angry
Euphoric
Stable
Not Assessed
Affect
Appropriate
Inappropriate
Labile
Constricted
Blunted
flat
Not Assessed
Safety Issues
None
Suicidal Ideations
Homicidal Ideations
Lethal Suicidal POA
Lethal Homicidal POA
Goals/Objectives Addressed
Goal/Objectives #1
Goal # Progress Rating
No Awareness/No Action
Some Awareness/Minimal Action
Inconsistent Action
Satisfactory Action w/ Support
Achieving
Goal/Objectives #2
Goal #2 Progress Rating
No Awareness/No Action
Some Awareness/Minimal Action
Inconsistent Action
Satisfactory Action w/ Support
Achieving
Goal/Objectives #3
Goal #3 Progress Rating
No Awareness/No Action
Some Awareness/Minimal Action
Inconsistent Action
Satisfactory Action w/ Support
Achieving
Session Techniques & Topics
TREATMENTS/ INTERVENTIONS TECHNIQUES
Behavioral
Family Therapy
Role Play
Problem Solving
Play Therapy
Psychoeducation
Treatment Plan.
Crisis Intervention
DBT
CBT
Art Therapy
Grief Counseling
Anger Management
TF-CBT
Music Therapy
Psychodrama
Movement Therapy
Faith-Based
Intake Session
Narrative Therapy
TOPICS/THEMES DISCUSSED
Interpers.Relation.
Work problems
School Problem
Child./Fx Origin
Identity/Role
Emotional Regulation
Parenting
Treatment Goals
Social Anxiety
Distress Tolerance
Family Dynamics
Communication Skills
Anxiety
Depression
Coping Skills
OCD
Trauma Work
Adjustment
Mindfulness
Spirituality
Loss
Body Image
Eating Disorder
Initial Interview
Body Awareness
Self-Esteem
Career
Thought-reframing
Pros/Cons
Non-judgemental Statements
Comments & Recommendations
Notes/Comments
Outcome
No significant change from previous session
Good continuation from previous session
Awareness is increasing with support
Actions are emerging but inconsistent
Self-monitoring is needed to sustain positive changes consistently
Emerging breakthrough being observed
Communication continues to be positive w/out resistance
Patient/Client's awareness/insights need to be backed up with consistent action
Satisfactory demonstration of skills learned today
satisfactory and meaningful communication with family support
Reviewed client currrent progress and ways that family can be of more effective support
troubleshooting correction of behavioral/communication setbacks with primary support system
improvements in motivation being detected/observed
referral to medical doctor is needed
follow up action is needed to achieve identified goal(s)
Other
Outcome
Recommendations
Continued Therapeutic Services, Skills Building, & Monitoring with same goals
Continued Therapeutic Services, Skills Building, & Monitoring with new goals
Step Down to Indirect and Monthly Monitoring
Discharge
Referral
To be determined
Signature: DONNA SAUNDERS, PH.D., PSYCHOLOGIST
Dr. Donna Saunders, Psychologist
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