HTML Preview Progress Note For Psychotherapy page number 1.
CAHC Resource Guide, 2012 1
Progress Note
START TIME ________ am pm
CLIENT NAME ___________________________________
STOP TIME ________ am pm
SERVICE Individual session Family session Group session Phone Call
CODE No Show Cancel/Reschedule Consultation _________________
SYMTOM STATUS improved maintained deteriorated DIAGNOSTIC CHANGE? no yes If yes, new
diagnosis:
LIST CURRENT SYMPTOMS ___________________________________________
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LIFE EVENT? no yes If yes, describe:
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MEDICATION compliance noncompliance side effect instructed to contact psychiatrist n/a
SAFETY suicidal homicidal none If yes, action taken:
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Check if goals/objectives section below N/A because treatment plan not yet completed per clinic policy
GOALS/OBJECTIVES ADDRESSED (from treatment plan)
Goal # ___ Objective # ___ Achieved? no partial yes Goal # ___ Objective # ___ Achieved? no partial yes
Goal # ___ Objective # ___ Achieved? no partial yes Goal # ___ Objective # ___ Achieved? no partial yes
OVERALL PROGRESS TOWARD GOAL: 1 2 3 4 5
NONE MIN MOD MAX MET
REVISED GOALS/OBJECTIVES? no yes If yes, Goal # ___ Objective # ___
new goal/objective:_____________________________________________________
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