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2 pages/≈550 words
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APA
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Health, Medicine, Nursing
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English (U.S.)
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Topic:

Group Therapy Progress Note: Documenting Family Session

Other (Not Listed) Instructions:

Assignment: Practicum – Week 2 Journal Entry (Due in Week 4)
Learning Objectives
Students will:
Apply documentation skills to examine family therapy sessions *
Develop diagnoses for clients receiving family psychotherapy *
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 3.
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.
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 (without violating HIPAA regulations) each client, and identify any pertinent history or medical information, including prescribed medications.
Using the Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM-5), explain and justify your diagnosis for each client.
Explain any legal and/or ethical implications related to counseling each client.
Support your approach with evidence-based literature.

Other (Not Listed) Sample Content Preview:
Group Therapy Progress Note
Client: _________Alex Richards_________________________________________ Date: _1/7/2021__________
Group name: ______Richards Family__________________________________________ Minutes: __45______
Group session # __3____ Meeting attended is #: _3_____ for this client.
Number present in group ___4__ of __4___ scheduled Start time: ___9:00_____ End time: __9:45______
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 Participation level: ❑ Active/eager ❑ Variable ❑ Only responsive ❑ Minimal ❑ Withdrawn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
Change in stressors: ❑ Less severe/fewer ❑ Different stressors ❑ More/more severe ❑ Chronic
Change in coping ability/skills: ❑ No change ❑ Improved ❑ Less able ❑ Mu...
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