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Sample Psychotherapy Note

Mrs. Little continues to experience symptoms of depression and anxiety during her psychotherapy session. She reports feeling sad, having reduced self-care, social isolation, and sleep problems. She discussed issues coping with depression and problems in her family, expressing feelings of loss and grief over the death of her husband last year. The therapist focused on facilitating communication of feelings and encouraged Mrs. Little to ask for help when depressed, deal with her grief through expression of feelings, and ventilate. Ways to reduce stress and joining a grief support group were also discussed.

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1K views2 pages

Sample Psychotherapy Note

Mrs. Little continues to experience symptoms of depression and anxiety during her psychotherapy session. She reports feeling sad, having reduced self-care, social isolation, and sleep problems. She discussed issues coping with depression and problems in her family, expressing feelings of loss and grief over the death of her husband last year. The therapist focused on facilitating communication of feelings and encouraged Mrs. Little to ask for help when depressed, deal with her grief through expression of feelings, and ventilate. Ways to reduce stress and joining a grief support group were also discussed.

Uploaded by

Rafael Sanchez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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This sample psychotherapy note was created in 3 minutes using the ICANotes Behavioral Health EHR.

The only words typed by the


clinician are highlighted in yellow. Visit http://www.ICANotes.com for a free trial or demo.

BEHAVIORAL HEALTH OUTPATIENT CLINIC


2121 Main Street
Anywhere, USA

Date of Exam: 6/9/2016


Time of Exam: 3:38:08 PM

Patient Name: Little, Aimee


Patient Number: 1000010659748

Psychotherapy Progress Note

Mrs. Little seems to have had an inadequate response to treatment as yet. Symptoms of depression continue to be
described. Her symptoms, as noted, are unchanged and they are just as frequent or intense as previously described.
Mrs. Little describes feeling sad. Mrs. Little denies suicidal ideas or intentions. Mrs. Little's anxiety symptoms continue.
Mrs. Little reports the symptoms of this disorder continue unchanged. The subjective feeling of apprehension is
occurring. Hypervigilance is occurring more frequently.

BEHAVIOR:
Her self care is reduced and less attention is being paid to these tasks. She reports the feeling that the performance of
domestic tasks has to be forced and are performed with difficulty. She is socially isolated. Sleep problems are reported.
Difficulty staying asleep is reported.

CONTENT OF THERAPY:
The patient today spoke mainly about issues involving coping with depression. Problems in the family were also
discussed by the patient. Mrs. Little shared the following pertinent details during this session: "I miss my husband
terribly and wonder if I will ever get over this." Feelings of loss were also expressed. Feelings of grief were also
expressed.

THERAPEUTIC INTERVENTION:
This session the therapeutic focus was on facilitating communication of feelings. Patient urged to ask for help and
support from staff member or therapist when feeling depressed. Aimee will use session to deal with grief over loss as
demonstrated by the expression of painful feelings along with associated affect. She was encouraged to ventilate. Ways
to reduce stress were also discussed with the patient.

Diagnoses:
Adjustment disorder with depressed mood, F43.21 (ICD-10) (Active)
Generalized anxiety disorder, F41.1 (ICD-10) (Active)
Histrionic personality disorder, F60.4 (ICD-10) (Active)

Instructions / Recommendations / Plan:


The risks and benefits of outpatient therapy were explained to Mrs. Little.
She was encouraged to join a grief support group held at her church.

Return 1 week, or earlier if needed.

Notes & Risk Factors:


Acute Grief: Death of husband 4/1/15

90834 Psychotherapy 45 min.


Time spent face to face with patient and/or family and coordination of care: 45 minutes
Session start: 9:00 AM
Session end: 9:45 AM

Anita Iten, LCSW

Electronically Signed
By: Anita Iten, LCSW
On: 6/9/2016 3:46:59 PM

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