Ac Progess Note

CHILDREN’S PROGRESS NOTE

Travel

Time:     

Client Name:      Date:      Service Code:      Duration:: Level of services provided: ACT Family Preservation 65(M) 65(N) Outpatient Substance Abuse Outpatient Intervention was provided: face to face with client with other supports with family Location: in home in office in hospital in school in community by phone no contact made with client Subjective /Objective Assessments: Subjective:. Mood: happy angry anxious agitated depressed other:      Behavior in Session: cooperative withdrawn oppositional hyperactive aggressive other:      Behavioral Issues: at school at home in community other N/A:      Developmental Issues: cognitive language motor/physical social none:      Relationship with Caregiver: good adequate disrupted nonexistent other:      Recent Substance use: caffeine cigarettes alcohol other drugs none denies not assessed:      Medication Effectiveness: reports “yes” reports “no” no change no psychiatric medication:      Harm self/others: thoughts/plan/actions: denies no indication of risk yes (if yes, give details below):      Other Observations/Assessments:      

Clinician Interventions (check any that apply)

Clinical Case Worker (check any that apply)

Identified current needs of client: Medical Social Psychiatric Educational Behavioral Other:     

Identified current needs of client: Medical Social Psychiatric Educational Behavioral Other:     

Provided aggressive outreach Developed/reviewed TRP/ Goals Provided psychotherapy to address individual goals Provided family therapy to stabilize family environment Assisted with crisis planning, intervention and follow-up Assisted with symptom and behavior management to reduce potential of out of home placement Development of strategies for relapse prevention Assisted caregiver/family in understanding client’s behavioral/developmental level and responding to identified treatment needs Provided support to improve effective communication and collaboration between family members Provided family education and consultation Monitored/ evaluated services provided Coordinated services within and between inpatient and community settings Provided supportive counseling/problem-solving activities Nursing(only) Provided education/assisted/monitored medications Provided health teaching re:_______________________ Other interventions:

Provided aggressive outreach Monitored TRP/Goals/Progress Assisted with crisis planning, intervention and follow-up Development of behavioral plans/strategies to manage, improve functioning & reduce potential for out of home placement Provided support/guidance to client/family Provided information, referral and problem-solving supports Linked to other services and supports Monitored/ evaluated services provided Coordinated services between home/school/community Coordinated services within and between inpatient and community settings Arranged for medication services Assisted client and family/caregiver in establishing natural supports Assisted with transition and discharge planning

Progress: Client made      progress on goal(s)     as evidenced by      Client’s symptoms/behaviors demonstrate the ongoing need for this level of care as evidenced by:      Plan: Continue Services per Treatment/Recovery Plan:. _________________________________________ Clinical Staff Signature

_________________________________________ Clinical Staff Signature

Ashley M. Crockett, MHRT/A Name (Printed)

      Name (Printed)

2166

Staff Code

      Staff Code

Children Progress Note Compfill 9-06