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Case Notes


COUNSELING SESSION PROGRESS NOTES: FIRST SESSION

Client’s first name (or pseudonym): _______________________________________________

Counselor: ___________________________________________ Date: __________________

Briefly describe the client’s presenting problem.

Describe the dynamics in the session (your own reactions to the client and the interactions between you and the client).
 
Describe other important information that was learned during the session, including contextual information.
 
Describe relevant cultural or development information as it relates to the presenting problem(s).
 
What is your initial conceptualization of the client’s issues(s)? (Be sure that your comments are theoretically sound.)

List relevant diagnostic impressions including code and axis.

To the extent possible, describe initial treatment plan for this client.

Based on your treatment plan, what are your objectives for the next session?

Share any personal reflections on the session

Questions to the supervisor/instructor.

_____________________________________ ____________________________________
Counselor Signature                                                     Supervisor/Instructor Signature Date


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COUNSELING SESSION PROGRESS NOTES

Client's first name (or pseudonym): _______________________________________________________

Counselor ________________________________________ Date _____________

What were your objectives for this session?

Describe the dynamics in the session (your own reactions to the client and the interactions between you and the client).
 
Summarize the key issues discussed during the session.

Describe relevant cultural or developmental information as it relates to the session or the client’s issue(s).

To what extent were your objectives for this session met?

Explain changes (or expansions) of your conceptualization of the problem(s).

List relevant diagnostic impressions including code and axis.

Explain changes (or expansions) of your treatment plan for this client.

Based on your treatment plan, what are your objectives for the next session?

Share any personal reflections on the session.

Questions to the supervisor/instructor?

___________________________________ ___________________________________
Counselor Signature­                                             Supervisor/Instructor Signature Date


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GROUP WORK PROCESS NOTES

Group Description____________________________________________ Date______________

Counselor _____________________________________________ Group Session # ______

What type of group is this? (counseling, psyco-ed, task, theme centered, open-ended, etc.) What is the theoretical approach? And why?

What were your goals and objectives for this group session?

What group dynamics did you observe? (Member roles, communication patterns, stage)

What leadership skills did you employ? (Scanning, linking, confrontation, trust-building, etc.)

Were your goals accomplished? Please explain

How do you assess the progress of this group?

Based on the stage of the group and the dynamics you observed, what are your process goals for the next session?

Questions/comments to the instructor

_____________________________________ ____________________________________
Counselor Signature                                                 Supervisor/Instructor Signature Date