The Adult Psychotherapy Progress Notes Planner. David J. Berghuis

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      1 Establish Rapport (1)²Caring was conveyed to the client through support, warmth, and empathy.The client was provided with nonjudgmental support and a level of trust was developed.The client was urged to feel safe in expressing his/her/their ADHD symptoms.The client began to express feelings more freely as rapport and trust level have increased.The client has continued to experience difficulty being open and direct about his/her/their expression of painful feelings; he/she/they were encouraged to use the safe haven of therapy to express these difficult issues.

      2 Focus on Strengthening Therapeutic Relationship (2)The relationship with the client was strengthened using empirically supported factors.The relationship with client was strengthened through the implementation of a collaborative approach, agreement on goals, demonstration of empathy, verbalization of positive regard, and collection of client feedback.The client reacted positively to the relationship-strengthening measures taken.The client verbalized feeling supported and understood during therapy sessions.Despite attempts to strengthen the therapeutic relationship the client reports feeling distant and misunderstood.The client has indicated that sessions are not helpful and will be terminating therapy.

      3 Conduct Psychosocial Assessment (3)A thorough psychosocial assessment was conducted, including the past and present symptoms of ADHD and their effects on educational, occupational, and social functioning.The psychosocial assessment reflects significant concerns related to ADHD, and this was communicated to the client.The psychosocial assessment reflects minimal concerns related to ADHD, and this was reflected to the client.

      4 Conduct/Refer for Psychological Testing (4)The client was administered psychological testing in order to establish or rule out the presence of an ADHD problem.Psychological testing has established the presence of an ADHD problem.The psychological testing failed to confirm the presence of ADHD.The psychological testing results were processed with the client to assist him/her/them in understanding his/her/their condition and to answer any questions that he/she/they might have.The client understood the explanation of the psychological testing and has accepted the presence of an ADHD problem.The client has denied the presence of ADHD and refused to accept the confirming results of the psychological testing; he/she/they were urged to be more open about this diagnosis.

      5 Refer for Physician Assessment Regarding Etiology (5)The client was referred to a physician to rule out nonpsychiatric medical etiologies for his/her/their ADHD.The client was referred to a physician to rule out substance-induced etiologies for his/her/their level of ADHD.The client has complied with the referral to a physician and the results of this evaluation were reviewed.The client has not complied with the referral for a medical evaluation and was redirected to do so.

      6 Process Medical and Psychological Evaluation (6)Results and recommendations of the medical evaluation were processed with the client and all questions were answered.The results and recommendations of the psychological evaluation were processed with the client and all questions were answered.As a result of the physician's evaluation, the client was prescribed medication to assist in the control of ADHD symptomatology.As a result of the psychological evaluation, the client was provided with several different techniques to assist in the control of ADHD symptomatology.

      7 Hold a Conjoint Session to Give Evaluation Feedback (7)A conjoint session was held with the client and his/her/their significant others in order to present the results of the psychological and medical evaluations.All questions regarding the evaluation results were processed.The client's family members were solicited for support regarding his/her/their compliance with treatment for his/her/their ADHD symptoms.The client's family members were verbally reinforced as they gave strong support to the client regarding medical and psychological treatment for his/her/their ADHD symptoms.

      8 Refer for Medication Evaluation (8)The client was referred to a prescribing clinician to evaluate him/her/them for psychotropic medication to reduce symptoms of ADHD.The client has completed an evaluation by the prescribing clinician and has begun taking ADHD medications.The client has resisted the referral to a prescribing clinician and does not want to take any medication to reduce ADHD levels; his/her/their concerns were processed.

      9 Monitor Medication Adherence (9)The client has begun taking medications for ADHD symptoms and the side effects and effectiveness were processed.The client has struggled to adhere to regularly taking medication for ADHD symptoms and his/her/their concerns were processed.The client has not begun taking medications for ADHD symptoms and was redirected to do so.

      10 Arrange Substance Abuse Evaluation (10)The client's use of alcohol and other mood-altering substances was assessed.The client was assessed to have a pattern of mild substance use.The client was assessed to have a pattern of moderate substance use.The client was assessed to have a pattern of severe substance use.The client was referred for a substance use treatment.The client was found to not have any substance use concerns.

      11 Assess Level of Insight (11)The client's level of insight toward the presenting problems was assessed.The client was assessed in regard to the syntonic versus dystonic nature of his/her/their insight about the presenting problems.The client was noted to demonstrate good insight into the problematic nature of the behavior and symptoms.The client was noted to be in agreement with others' concerns and is motivated to work on change.The client was noted to be ambivalent regarding the problems described and is reluctant to address the issues as a concern.The client was noted to be resistant regarding acknowledgment of the problem areas, is not concerned about them, and has no motivation to make changes.

      12 Assess for Correlated Disorders (12)The client was assessed for evidence of research-based correlated disorders.The client was assessed in regard to his/her/their level of vulnerability to suicide.The client was identified as having a comorbid disorder, and treatment was adjusted to account for these concerns.The client has been assessed for any correlated disorders, but none were found.

      13 Assess for Culturally Based Confounding Issues (13)The client was assessed for age-related issues that could help to better understand his/her/their clinical presentation.The client was assessed for gender-related issues that could help to better understand his/her/their clinical presentation.The client was assessed for cultural syndromes, cultural idioms of distress, or culturally based perceived causes that could help to better understand his/her/their clinical presentation.Alternative factors have been identified as contributing to the client's currently defined “problem behavior,” and these were taken into account СКАЧАТЬ