This is the progress note page, the only thing making notes on in for this recording this the getting to know you introduction. Not treatment or diagnose and not planning only written about worker meeting client for the first time. I put some question in the box below to help guide . Answer all question and the Recording of Interview: section must be 2 or more pages written in this section below.
Include who participated in the session, the setting (office, home visit, phone, etc.), general impressions of client’s appearance and behavior, and purpose for the meeting. Please disguise client name and identifying information.
It was my student team or us who participated in the session. The client is coming into the office for support and knowledge of how to get out of the slump he feels he is in. He wants his life back get up and get a job and move out his parents home
50 year old caucasian man, who has lived at home with his parents for the last 10 years. He has been given diagnoses of Psychotic Disorder, NOS, Schizoaffective Disorder and Major Depression. He is sometimes hears background chatter that has been explained to him as auditory hallucinations by his providers. These symptoms can be very distracting and disturbing, he reports spending a lot of time trying to separate these hallucinations from reality. He knows how to manage his recovery with therapeutic support and life activities, but he can’t seem to get back to it living at his parents house. He would like to see if a new medication regime would help him. When he has lived on his own, He has had periods of greater and lesser symptom interference; he has some idea of what contributes to the changes. When his symptoms are at their worst, he becomes depressed and neglects his self-care, eating poorly or neglects to eat regularly, ignores his bills, and bathes less. He’s primary concern is his boredom and not getting along with his dad. He would like to get a job and move out of his parent’s home. He is feeling uncertain about how to accomplish his goals.
Student Learning Goals:
Identify 1-2 learning goals for the session, for example, explore affect, ask open-ended questions, intervene using a cognitive behavioral approach, etc.
Traits about pastime sessions with other workers Client stated that all has past experience he liked. but he session with us he liked because we didn’t not ask about his diagnosis
What prompted the start of therapy His mother his him to go, she is his support.
How was your life before this problem, when you were living on your own. He enjoyed his life going out with friends and he loves working with his hands doing computer coding and programing. He wants to get a job in work with computers like coding etc.
Day to Day Activities He does not go out has no relationship and stay in his room because he dont want to here his father complain or speak down to him.
Recording of Interview:
Text in gray below is there to guide you as your fill in your process recording. You may delete that information after you know what is expected in each area. This section should be at least 2 pages. Please note: In the in-person placement, this section is to be 4 pages in length.
Student – Client Interaction Dialogue
Rationale for Intervention
(Beginning students should record all interactions, verbal and non-verbal. As the first year progresses students will become more selective and develop better recall of the interview and key interactions and use of words. By the end of the first year and in second year, the recordings should take less time and will focus on learning goals like diagnostic assessments, sitting with or pursuing affect, beginnings or endings, listening skills, etc.)
(Worker shares their affective and cognitive reflections about the client, the interview, and worker’s use of self. This is a place to critique one’s work and progress in mastering interviewing skills, planned interventions, self-awareness of counter-transference feelings, reflections about areas of diversity- i.e. race/ethnicity, class, religion/spirituality, sexual orientation, etc.) , and integration of theory with observations.
(Rationale for intervention: includes application of theory, reasons for choosing a particular intervention, use of evidence informed practice.)
What are your impressions about how you handled the interview? What are your thoughts about your client’s progress? How do you understand your role?
Reflection on Social Identity, Policy, Research or Ethics:
Choose one or more of the following topics to reflect on for this session.
1. How do aspects of your and your client’s social identity impact your work with this client?
2. How might social policies impact your client? What barriers are impacting your client at the community level? How do they affect your work with the client?
3. What question do you have about this client or context that research might help you to better intervene or advocate?
4. What ethical dilemmas have arisen in this clinical situation and what questions do you have?
What is the plan for future sessions?
Questions for Supervision:
Which aspects of the interview would you like feedback on? What questions do you have for your field instructor?
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