group note

 

• Develop effective documentation skills for family therapy sessions *
• Develop diagnoses for clients receiving family psychotherapy *
• Evaluate the efficacy of solution-focused therapy and cognitive behavioral therapy for families *
• Analyze legal and ethical implications of counseling clients with psychiatric disorders *

* The Assignment related to this Learning Objective is introduced this week and submitted in Week 7.
 

Select two clients you observed or counseled this week during a family therapy session. Note: The two clients you select must have attended the same family session. Do not select the same family you selected for Week 2.

Then, address in your Practicum Journal the following:

• Using the Group Therapy Progress Note in this week’s Learning Resources, document the family session.
• Describe each client (without violating HIPAA regulations) and  identify any pertinent history or medical information, including  prescribed medications.
• Using the DSM-5, explain and justify your diagnosis for each client.
• Explain whether solution-focused or cognitive behavioral therapy  would be more effective with this family. Include expected outcomes  based on these therapeutic approaches.
• Explain any legal and/or ethical implications related to counseling each client.
• Support your approach with evidence-based literature.

Group Therapy Progress Note

American Psychological Association | Division 12 http://www.div12.org/ 1

Client: __________________________________________________ Date: ___________
Group name:________________________________________________ Minutes:________
Group session # ______ Meeting attended is #:______ for this client.
Number present in group _____ of _____ scheduled Start time:________ End time: ________

Assessment of client

1. Participation level: ❑ Active/eager ❑ Variable ❑ Only responsive ❑ Minimal ❑ Withdrawn

2. Participation quality: ❑ Expected ❑ Supportive ❑ Sharing ❑ Attentive ❑ Intrusive

❑ Monopolizing ❑ Resistant ❑ Other: _____________________________________

3. Mood: ❑ Normal ❑ Anxious ❑ Depressed ❑ Angry ❑ Euphoric ❑ Other: _______________

4. Affect: ❑ Normal ❑ Intense ❑ Blunted ❑ Inappropriate ❑ Labile ❑ Other:_______________

5. Mental status: ❑ Normal ❑ Lack awareness ❑ Memory problems ❑ Disoriented ❑ Confused

❑ Disorganized ❑ Vigilant ❑ Delusions ❑ Hallucinations ❑ Other:__________________

6. Suicide/violence risk: ❑ Almost none ❑ Ideation ❑ Threat ❑ Rehearsal ❑ Gesture ❑ Attempt

7. Change in stressors: ❑ Less severe/fewer ❑ Different stressors ❑ More/more severe ❑ Chronic

8. Change in coping ability/skills: ❑ No change ❑ Improved ❑ Less able ❑ Much less able

9. Change in symptoms: ❑ Same ❑ Less severe ❑ Resolved ❑ More severe ❑ Much worse

10. Other observations/evaluations:________________________________________________________

In-session procedures:

 _______________________________________________________________________________

 _______________________________________________________________________________
 _______________________________________________________________________________
 _______________________________________________________________________________

 __________ _____________________________________________________________________

Homework:
1.

2.

3.

Other Comments:
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Signatures Date