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:
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Order Paper Now- 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.
- 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 Participation level: ❑ Active/eager ❑ Variable ❑ Only responsive ❑ Minimal ❑ Withdrawn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: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Signatures Date
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