Client Information:
- Client Name: Emily Johnson
- Provider Name: Dr. Sarah Thompson
- Date of Service: 1 November 2024
- Session Duration: 45 minutes
Behavior:
Emily appeared anxious and avoided eye contact at the beginning of the session. Her mother reported that Emily has been having frequent nightmares and is reluctant to attend school.
Intervention:
The therapist engaged Emily in play therapy using a sand tray to help her express her feelings about school. Dr. Thompson also guided Emily's mother on how to comfort Emily during her nightmares.
Response:
Emily gradually became more relaxed and started to share her thoughts about school through the sand tray activity. She mentioned feeling 'scared' and 'lonely' at school.
Plan:
The therapist will continue with play-based interventions and introduce relaxation techniques in the next session. A follow-up meeting with Emily's mother is scheduled to discuss strategies for easing Emily's school-related anxiety.
Client Information:
- Client Name: [Insert client name here] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- Provider Name: [Insert provider name here] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
- Date of Service: [Insert date of service here]
- Session Duration: [Insert session duration here]
Behavior:
[Describe the child’s presenting behavior, including their physical appearance, orientation, and emotional state. Document any behaviors or statements made by the child and relevant observations by caregivers. For example: "The child appeared withdrawn and refused to make eye contact at the start of the session," or "The parent reported the child has been experiencing frequent tantrums at home."] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
Intervention:
[Detail the therapeutic strategies or interventions employed during the session, such as play therapy, sand tray techniques, or other age-appropriate activities. Include any caregiver engagement or guidance provided. For example: "The therapist used role-playing with figurines to explore the child’s feelings about a recent family conflict."] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
Response:
[Summarize the child’s response to the interventions, including any observed changes in behavior, emotional state, or level of engagement. For example: "The child became more verbal and expressive during play, stating that the toys felt 'sad like me.'"] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
Plan:
[Outline next steps, such as follow-up sessions, planned interventions, or caregiver strategies to support the child between sessions. For example: "The therapist will continue to use play-based interventions and introduce emotion identification exercises next session. A parent consultation will be scheduled to review strategies for managing outbursts at home."] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)