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Psychotherapy Progress Note: Intervention(s) Used

This psychotherapy progress note documents a client's therapy session. It records information about the client's appearance, behavior, mood, affect, thought process, thought content, insights, and response to treatment. The therapist used various interventions such as cognitive restructuring, communication training, and homework assignments. The client's status is noted as improving. Their next appointment is scheduled.

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Paola Buffit Torres
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213 views1 page

Psychotherapy Progress Note: Intervention(s) Used

This psychotherapy progress note documents a client's therapy session. It records information about the client's appearance, behavior, mood, affect, thought process, thought content, insights, and response to treatment. The therapist used various interventions such as cognitive restructuring, communication training, and homework assignments. The client's status is noted as improving. Their next appointment is scheduled.

Uploaded by

Paola Buffit Torres
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PSYCHOTHERAPY PROGRESS NOTE Mental Health CPT Codes

PRESENT: Client 90791 Initial Evaluation


90834 Indv.Therapy (38-52 min)
90837 Indv.Therapy (53+ min)
90847 Couple/Family Therapy
DATE: _ _/_ _/_ _ Medication(s) Status: 90846 Couple/Family Session
SESSION: without Client Present

Appearance
APPROPRIATE DRESS Intervention(s) used
Response to Tx
APPROPRIATE GROOMED
POORLY DRESSED ANGER MANAGEMENT INVOLVING OF SIGNIFICANT OTHERS ENGAGED
POORLY GROOMED ART THERAPY PSYCHOEDUCATION RECEPTIVE
DISHEVELED ATTACHMENT THERAPY MINDFULNESS TRAINING UNINTERESTED
Behaviors BUILDING SUPPORT SYSTEM MUSIC THERAPY COMBATIVE
APPROPRIATE
COGNITIVE RESTRUCTURING PROBLEM-SOLVING SKILLS COOPERATIVE
POOR EYE CONTACT
COMMUNICATION TRAINING ROLEPLAY Other:
DISTANT
HOSTILE DECISION CLARIFICATION SOMATIC WORK
INATTENTIVE DEVELOPING COPING STRATEGIES SOLUTION-FOCUSED TECHNIQUES
ANXIOUS DREAMWORK STRESS MANAGEMENT Patient Status
Orientation HOMEWORK ASSIGNMENTS SUPPORTIVE REFLECTION IMPROVING
PERSON
EXPLORATION OF FEELINGS PROVIDE REFERRALS: UNCHANGED
PLACE
GRIEF PROCESSING OTHER: DETERIORATING
TIME
SITUATION EMDR Other:
Mood
DEPRESSION
ANXIOUS SESSION CONTENT
IRRITABLE
ANGRY
ELATED
EUTHIMIC
Affect
APPROPRIATE
DEPRESSED
LABILE
FLAT
BLUNT
EXPANSIVE
Insights
EXCELLENT
GOOD
FAIR
POOR
IMPAIRED
Other:
Thought Process
WNL
CIRCUMSTANTIAL
TANGENTIAL
LOOSE
IDEA FLIGHT
WORD SALAD
Thought Content
WNL
PREOCCUPATION
PLAN
DEREALIZATION
DEPERSONALIZATION
HALLUCINATIONS
DELUSIONS
Judgment
EXCELLENT
GOOD
FAIR
POOR
IMPAIRED
Other:

Signature: NEXT APPT SCHEDULED ON: _ _/_ _/_ _

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