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    Psychotherapy Progress Note

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    Armaan Malik
    Andrea is making progress in her recovery from alcohol abuse. She reports substituting exercise for drinking with friends and denies symptoms of anxiety, dysphoria, or sleep issues. Andrea attends AA regularly, provides clean urine samples, and has maintained sobriety. Therapy focused on increasing insight into her substance abuse and shame, as well as identifying triggers for unproductive behaviors. Her therapist set a short term goal for Andrea to plan a non-drinking recreational activity and recommends revising her treatment plan goals at the next meeting given her excellent progress.

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    Psychotherapy Progress Note

    Uploaded by

    Armaan Malik
    2K views1 page
    Andrea is making progress in her recovery from alcohol abuse. She reports substituting exercise for drinking with friends and denies symptoms of anxiety, dysphoria, or sleep issues. Andrea attends AA regularly, provides clean urine samples, and has maintained sobriety. Therapy focused on increasing insight into her substance abuse and shame, as well as identifying triggers for unproductive behaviors. Her therapist set a short term goal for Andrea to plan a non-drinking recreational activity and recommends revising her treatment plan goals at the next meeting given her excellent progress.

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    Session notes

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    Andrea is making progress in her recovery from alcohol abuse. She reports substituting exercise for drinking with friends and denies symptoms of anxiety, dysphoria, or sleep issues. Andrea attends AA regularly, provides clean urine samples, and has maintained sobriety. Therapy focused on increasing insight into her substance abuse and shame, as well as identifying triggers for unproductive behaviors. Her therapist set a short term goal for Andrea to plan a non-drinking recreational activity and recommends revising her treatment plan goals at the next meeting given her excellent progress.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    2K views1 page

    Psychotherapy Progress Note

    Uploaded by

    Armaan Malik
    Andrea is making progress in her recovery from alcohol abuse. She reports substituting exercise for drinking with friends and denies symptoms of anxiety, dysphoria, or sleep issues. Andrea attends AA regularly, provides clean urine samples, and has maintained sobriety. Therapy focused on increasing insight into her substance abuse and shame, as well as identifying triggers for unproductive behaviors. Her therapist set a short term goal for Andrea to plan a non-drinking recreational activity and recommends revising her treatment plan goals at the next meeting given her excellent progress.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 1

    Psychotherapy Progress Note

    Psychiatric Social Worker

    Date of Exam: 4/28/2012


    Time of Exam: 9:00:56 AM

    Patient Name: Conner, Andrea


    Patient Number: 1000010644560

    Improvement is occurring. "My social life now revolves around exercise instead of drinking with my friends."

    Problem Pertinent Review of Symptoms:


    Feelings of anxiety are denied. Andrea denies experiencing dysphoric moods. Sleep disturbance is not reported. Andrea describes rare
    substance cravings. She denies the temptation to use. Andrea denies use. Andrea reports that she has been regularly attending AA
    meetings. A sample for urine drug screening was obtained. She has maintained sobriety. Impulsive behaviors are not reported.

    Content of Therapy: The patient's substance abuse problems were the main issue this session. Feelings of shame were also
    expressed.

    Therapeutic Interventions: The focus of today's session was on helping the patient increase insight and understanding. The main
    therapeutic techniques used involved the exploration of the patterns of certain behaviors. Therapeutic efforts also included aiding the
    patient in identifying the precipitants of unproductive feelings and behaviors. . The importance of abstinence was also reviewed.

    MENTAL STATUS: Andrea is alert, attentive, casually groomed, and relaxed. She exhibits speech that is normal in rate, volume, and
    articulation and is coherent and spontaneous. Language skills are intact. Mood is entirely normal with no signs of depression or mood
    elevation. Affect is appropriate, full range, and congruent with mood. Insight into illness is normal. Social judgment is intact. Signs of
    chemical withdrawal are exhibited by Andrea. Mild signs of anxiety which appear to be secondary to withdrawal are present.

    DIAGNOSES: The following Diagnoses are based on currently available information and may change as additional information
    becomes available.

    Axis I: Alcohol Abuse, 305.00 (Active)

    INSTRUCTIONS / RECOMMENDATIONS / PLAN:

    Link to Treatment Plan Problem: Substance Abuse

    Short Term Goals:


    Andrea will make plans for a recreation activity that does not involve alcohol or drugs, within one week.
    Target Date: 4/29/2012
    ---------------------------------
    Excellent progress in reaching these goals and resolving problems seemed evident today.
    Recommend that the interventions and short term goals for this problem be re-written at the next Treatment Team meeting.
    --------------------------------

    Return 2 weeks or earlier if needed.

    NOTES & RISK FACTORS:


    History of Subst. Abuse

    90806 PSYTX, Office, 45-50 MIN

    Time spent counseling and coordinating care: 45-50 min

    Session start: 9:00 AM


    Session end: 9:50 AM

    John Smith, LCSW

    Electronically Signed
    By: John Smith, LCSW
    On: 4/22/2012 11:07 AM

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