#Example of counselling session notes professional#

What were the treatment priorities for the client? How were they determined? This section serves as a transition from assessment to treatment conceptualization. Upon completion of your assessment, what did you decide was pertinent to treatment, and why?.A genogram will help you assess and document this information, which can be included as an appendix in your case summary. What is the client's relational/systemic reality, including significant relationships as well as relational difficulties?ĭescribe significant relationships, relational conflicts, cut-offs, closeness, and relational patterns.Therapist secured releases of information for Sarah's psychiatrist and primary care physician, and also completed a basic genogram covering three generations of Sarah's family.ĭescribe the clients' relevant demographic information and socio-cultural contexts, including home, work, significant relationships, and socio-economic status, among others. Were any releases of information necessary for a thorough assessment?įor example: Assessment information was gathered informally, over the course of three sessions. Was there a formal assessment process involving a bio/psycho/social, or was assessment more informal?

How did you assess information for the case?.

She has begun exploring family of origin patterns of depression and parentification. Sarah’s presenting problem continues to be her immediate family conflict however, she has also explained that her family of origin history is relevant to her symptoms of depression. This has relieved the tension between them. She and her husband are in concurrent couples therapy and have negotiated setting boundaries with their daughter.

How has the presenting problem changed over time?įor example: Currently, Sarah is taking medication for symptoms of MDD.

According to Sarah, she advocates for her daughter, while her husband wants to kick their daughter out of the house. Their daughter is living in their home and doesn't have a job this is affecting the couple's financial stability. These symptoms have been present for two years, since she and her husband began having marital conflict due to disagreements about their adult daughter. She complained of difficulty sleeping, lethargy, and periods of crying, without a clear cause.

What was the initial presenting problem? (State in diagnostic, behavioral, and relational terms).įor example: Sarah presented to therapy with a diagnosis of Major Depressive Disorder (MDD), provided during an initial psychiatric evaluation.

How long have the clients been in therapy with you, or at your agency?.

In this section, summarize essential details related to the history of the case, both before you were the therapist (if relevant) as well as during your work with the client(s).

#Example of counselling session notes professional#

You may need to write a case report as part of a class, your job’s paperwork requirements, for billing purposes, to comply with professional providers, or other reasons. The information in this post will serve as a simple template for organizing your case information and ensuring that all relevant details are present in your summary. In this post, I outline and explain the sections of the case summary assignment. In the practicum courses I teach, students are required to write a case summary and present the case to the class. Conceptualizing a case systemically can be challenging, because of the many family members and influences that are relevant to our work with clients.