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Psychotherapy DAP Note

Andrea Conner attended a psychotherapy session to address her substance abuse problems and feelings of shame. She reports maintaining sobriety, attending AA meetings regularly, and replacing drinking with friends with exercise. The session focused on helping her increase insight into behaviors and identifying triggers. Her mental status was normal with mild signs of anxiety from withdrawal. She was diagnosed with alcohol abuse but is making excellent progress in her treatment goals. The social worker recommends rewriting her short term goals at the next treatment team meeting and scheduling a follow up in two weeks.

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1K views2 pages

Psychotherapy DAP Note

Andrea Conner attended a psychotherapy session to address her substance abuse problems and feelings of shame. She reports maintaining sobriety, attending AA meetings regularly, and replacing drinking with friends with exercise. The session focused on helping her increase insight into behaviors and identifying triggers. Her mental status was normal with mild signs of anxiety from withdrawal. She was diagnosed with alcohol abuse but is making excellent progress in her treatment goals. The social worker recommends rewriting her short term goals at the next treatment team meeting and scheduling a follow up in two weeks.

Uploaded by

Mistor Williams
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Psychotherapy DAP 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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