Group Therapy Progress Note

Group Therapy Progress Note

Learning Objectives

Students will:

• Develop effective documentation skills for family therapy sessions *
• Develop diagnoses for clients receiving family psychotherapy *
• Evaluate the efficacy of solution-focused therapy and cognitive behavioral therapy for families *
• Analyze legal and ethical implications of counseling clients with psychiatric disorders *

Select two clientsyou observed or counseled this week during a family therapy session. Note: The two clients you select must have attended the same family session. Do not select the same family you selected for Week 2.

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Then, address in your Practicum Journal the following:

• Using the Group Therapy Progress Note in this week’s Learning Resources, document the family session.
• Describe each client (without violating HIPAA regulations) and identify any pertinent history or medical information, including prescribed medications.
• Using the DSM-5, explain and justify your diagnosis for each client.
• Explain whether solution-focused or cognitive behavioral therapy would be more effective with this family. Include expected outcomes based on these therapeutic approaches.
• Explain any legal and/or ethical implications related to counseling each client.
• Support your approach with evidence-based literature.
• BLANK NOTES INCLUDED THAT NEED TO BE FILLED OUT

SAMPLE ANSWER

Group Therapy Progress Note American Psychological Association

Client: James Henry Date:  October 5^th , 2019 Group name: Henrys Minutes: 40 minutes Group session # 5 Meeting attended is #: 5 for this client. Number present in group 2 of 2. Scheduled Start time: 10.40 am End time: 11.20am.

Assessment of client  1. Participation level: ❑ Active/eager ❑ Variable ❑ Only responsive ❑ Minimal ❑ Withdrawn

2. Participation quality: ❑ Expected ❑ Supportive ❑ Sharing ❑ Attentive ❑ Intrusive ❑ Monopolizing ❑ Resistant ❑ Other: _____________________________________
3. Mood: ❑ Normal ❑ Anxious ❑ Depressed ❑ Angry ❑ Euphoric ❑ Other: _______________
4. Affect: ❑ Normal ❑ Intense ❑ Blunted ❑ Inappropriate ❑ Labile ❑Other:_______________
5. Mental status: ❑ Normal ❑ Lack awareness ❑ Memory problems ❑ Disoriented ❑ Confused ❑ Disorganized ❑ Vigilant ❑ Delusions ❑ Hallucinations ❑Other:__________________
6. Suicide/violence risk: ❑ Almost none ❑ Ideation ❑ Threat ❑ Rehearsal ❑ Gesture ❑ Attempt
7. Change in stressors: ❑ Less severe/fewer ❑ Different stressors ❑ More/more severe ❑ Chronic
8. Change in coping ability/skills: ❑ No change ❑ Improved ❑ Less able ❑ Much less able
9. Change in symptoms: ❑ Same ❑ Less severe ❑ Resolved ❑ More severe ❑ Much worse 10.

Other observations/evaluations:

The patient shows normal physical health

In-session procedures:

The session used cognitive behavioral therapy as a technique for enhancing counseling.

Homework: 1. 2. 3.

Other Comments:

The client is stabilizing  from his depression.

Group Therapy Progress Note American Psychological Association

Client: Adelide Henry Date:  October 5^th , 2019 Group name: Henrys Minutes: 40 minutes Group session # 5 Meeting attended is #: 5 for this client. Number present in group 2 of 2. Scheduled Start time: 10.40 am End time: 11.20am.

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Assessment of client  1. Participation level: ❑ Active/eager ❑ Variable ❑ Only responsive ❑ Minimal ❑ Withdrawn

2. Participation quality: ❑ Expected ❑ Supportive ❑ Sharing ❑ Attentive ❑ Intrusive ❑ Monopolizing ❑ Resistant ❑ Other: _____________________________________
3. Mood: ❑ Normal ❑ Anxious ❑ Depressed ❑ Angry ❑ Euphoric ❑ Other: _______________
4. Affect: ❑ Normal ❑ Intense ❑ Blunted ❑ Inappropriate ❑ Labile ❑Other:_______________
5. Mental status: ❑ Normal ❑ Lack awareness ❑ Memory problems ❑ Disoriented ❑ Confused ❑ Disorganized ❑ Vigilant ❑ Delusions ❑ Hallucinations ❑Other:__________________
6. Suicide/violence risk: ❑ Almost none ❑ Ideation ❑ Threat ❑ Rehearsal ❑ Gesture ❑ Attempt
7. Change in stressors: ❑ Less severe/fewer ❑ Different stressors ❑ More/more severe ❑ Chronic
8. Change in coping ability/skills: ❑ No change ❑ Improved ❑ Less able ❑ Much less able
9. Change in symptoms: ❑ Same ❑ Less severe ❑ Resolved ❑ More severe ❑ Much worse 10.

Other observations/evaluations:

The patient shows coherence in communication with a stable mental orientation

In-session procedures:

The session used cognitive behavioral therapy.

Homework: 1. 2. 3.

Other Comments:

The client depicts some anxiety symptoms.

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