Psychosocial Rehabilitation Progress Note

Psychosocial Rehabilitation Progress Note

Psychosocial Rehabilitation Progress Note

CLIENT NAME:	Service Code: H2017 DIAGNOSIS:
Case #:	Setting 53 CMHC GT	Service Date:	TOTAL UNITS: 16	Total hours: 4
Begin-End Time	8:00AM TO 9:00AM	9:00AM TO 10:00AM	10:00AM TO 11:00AM	11:00AM TO 12:00PM
Session Number/units	Section 1: 4 Units	Section 2: 4 Units	Section 3: 4 Units	Section 4: 4 Units

GOALS/OBJECTIVE ADDRESSED FROM CLIENTS TREATMENT PLAN:

☒ Goal 1:

Learn to Identify the early warnings signs of depressed mood and the preventative actions to take.

☐ Goal 2:

Decrease client’s overall anxiety symptoms and help client implement more positive behaviors that support decreased feelings and thoughts that produce anxiety.

☐ Goal 3:

Help client learn new ways to improve sleep patterns and increase overall restful sleep.

OBSERVATIONS	INTERVENTIONS UTILIZED	PATIENT’S RESPONSE TO INTERVENTION	ASSESSMENT OF PROGRESS/OUTCOME
Attentive ☒ Inattentive ☐ Angry ☐ Sad ☐ Flat Affect ☐ Anxious, tense ☐ Positive Effect, mood☒ Oriented 3x ☒ Impulsive ☐ Labile ☐ Withdrawn ☐ Relates Well ☒ Decreased eye contact☐ Appropriate/ate eye contact☒ Other:	Individual Therapy ☐ PSR ☒ Behavior Modification ☐ Psychoeducation ☐ Conflict Mediation ☐ Cognitive/Behavioral ☐ Activity-Based Therapy ☐ Relaxation/Meditation ☐ Anger Management ☐ Social Skills ☐ Communication-relation Skills ☐ Treatment Progress Reviewed ☐ Career/Vocational Planning ☐ Expressive Modalities ☐ Other:	Cooperative ☒ Uncooperative ☐ Assertive ☐ Passive ☐ Aggressive ☐ Non-Responsive ☐ Resistant ☐ Engaged/Active ☒ Variable ☒ Other:	Minimal ☐ Slow ☒ Steady ☐ Good/Excellent ☐ Increased difficulties noted ☐ Complicated by recent stressors ☐ Developing insight ☒ Aware, Insightful ☐ Able to generate alternatives ☐ Initiates problem-solving ☒ Problem solved with the assistance ☒ Demonstrates empathy, support for others ☒ Uses sessions to vent ☒ Variable ☐

SKILL SETS ADDRESSED/ACTIVITIES PROVIDED BY FACILITATOR TO BUILD CLIENT SKILLS:

Activity 1:

Activity facilitator’s intervention :

Participation: Cooperative ☒ Uninterested ☐ Distractible ☐ Confused ☐ Other:_______________

Activity 2:

Activity facilitator’s intervention:

Participation: Cooperative ☒ Uninterested ☐ Distractible ☐ Confused ☐ Other:_______________

Activity 3:

Activity facilitator’s intervention :

Participation: Cooperative ☒ Uninterested ☐ Distractible ☐ Confused ☐ Other:_______________

Activity 4:

Activity facilitator’s intervention:

Participation: Cooperative ☒ Uninterested ☐ Distractible ☐ Confused ☐ Other:_______________

The client benefited by:

Facilitator’s Signature/Credentials

Clinical Director Name, /Credentials

Date

Psychosocial Rehabilitation Progress note 1