Using the subjective, hand-written portion of your psychotherapy note, create a narrative that explains in short form the major features of the session. Max 750 Characters. EXAMPLE: Katie presented in today's session feeling “depressed. She stated that her mood has been “getting worse.” She reported that she has been struggling to get out of the house to enjoy social events that she is actually interested in, then becomes more frustrated with herself. She described an increase in sleep issues both difficulty falling asleep and staying asleep. Katie says that she “just wants to be better.” Katie continues to endorse low energy, loss of interest in activities, difficulty sleeping and feelings of guilt, although she is not able to express the source of her guilt.

Using the objective parts of your psychotherapy note (i.e., mental status exam, assessment of issues presented boxes, intervention used, etc.) , create a narrative that explains in short form the objective major features of the session. Max 1000 Characters. EXAMPLE: Therapist helped Katie process her feelings, provided in depth psychoeducation on guilt and how it relates to depression. Katie's mood throughout the session was low, flat affect, her speech is low volume and soft. Therapist used the CBT triangle in session to assess Katie’s ability to identify patterns in behavior and thoughts. Katie required extensive guidance to understand the concept of the thought triangle. Therapist explored her feelings of guilt at-length, and used socratic questioning to fully engage with past experiences that may be triggering guilt/shame. Therapist helped Katie process how her feelings influence her behavior (CBT triangle) and discussed in depth behavioral patterns that potentially are increasing her depressive symptoms.

Using the assessment of issues presented boxes and your general impression of functioning, create a narrative that explains in short form your assessment of client progress as of the date of the session being documented. Max 1000 Characters. EXAMPLE: Katie continues to struggle with depressive symptoms, primarily guilt, making it difficult to engage with her surroundings as she desires. She lacks insight into her diagnosis, often saying things like “if i don't want to be depressed than why am i depressed,” she required extensive socratic questioning to help her gain a little more insight into her diagnosis and feelings of guilt/shame. She denies SI/HI/AVH. She is struggling to make progress toward her goal of identifying triggers or past experiences that contribute to her feelings of guilt and worthlessness, as she requires redirection to provide relevant examples and/or to clarify her comments.

Using Summary Evaluation/Prognosis/Assessment portion of your psychotherapy note , create a narrative that explains in short form the ongoing plan as of the date of the session being documented. Max 750 Characters. EXAMPLE: Therapist will continue to use CBT informed treatment to help Katie learn coping skills to manage depression symptoms specifically guilt. For the next week therapist asks Katie to consider her core beliefs and the source of her core beliefs. She was provided a worksheet to help clarify what core beliefs are and some potential sources. Therapist and Katie agreed to meet again in one week.