PLEASE RE-WRITE EACH NOTE KEEPING THE LISTED NAME BY THE RE-WRITTEN PORTION. THE

PLEASE RE-WRITE EACH NOTE KEEPING THE LISTED NAME BY THE RE-WRITTEN PORTION. THESE NOTES SHOULD BE WRITTEN AS IF YOURE A CLINICAL THERAPIST
Robert1:
At the time of this session, client presented in a fair mood. Client described still
getting caught up on school work as the quarter for grades were coming to an end, client had been
working with teachers for extra credit work. Client mentioned cutting back on exercising to focus on
completing missed assignments but plans to start back working out once he finishes catching up.
Therapist questioned client on current well-being and comfortability with placement, client currently still
spends time home alone during the week but this does not present as a problem for the client as of the
moment and client enjoys the alone time. Therapist reminded client to attempt building friendly relationship
with others while in school, along with maintaining those healthy relationships and boundaries. Therapist
and client mutually agreed that client will attempt to not eat lunch alone but sit with one-two peers and
socialize, client will verbalize if he began to feel an urge to self-harm by spending excessive time in the
placement alone, client was receptive and will seek support if needed.
IVY 1:
During this session, Client admits feeling overwhelmed and anxious even when
completing the smallest projects, client expressed getting frustrated and giving up. The main therapeutic
technique used this session involved helping the client to identify areas of difficulty and to develop coping
skills and to manage stress and anxiety. The therapist goal this session was to help the client focus on
improving the clients self-compassion and encouraging the client to make positive statements regarding
self and the ability to cope with the stresses of life. Therapist reminded client of the important of
presenting with appropriate behaviors in school and maintaining good grades even when symptoms of
anxiety are present. Therapist reminded client of the previous suggestions that were provided during
previous sessions, that would help client improve in affected areas such as utilizing recess or lunch breaks
to socialize with friends, completing missed homework assignments at home and not at school, and
avoiding social media. Client was receptive, therapist will meet with client for next session to check for improvements.
ivy2: During this zoom session, Client symptoms of anxiety continued to be described.
Client expressed that the symptoms were intense and frequent during school hours. Client described
trouble remaining focus during lectures and an urge to move around. Therapist noted that client self-care
had reduced and was less attentive during previous sessions, client reported that the performance of
domestic tasks had to be forced and were sometimes preformed with difficulties. During this session the
therapist focused on facilitating communication of feelings, Client was urged to ask for help and support
from OCH staff and/or placement family. Client was encouraged to ventilate ways to reduce stress. Client
was encouraged to seek school counselor if anxiety levels continue to increase while at school.
ivy3: During this session client sat attentive and willing to engage with therapist.
Therapist questioned client on current mood as previous session client mentioned still dealing with fears
that contributed to symptoms of anxiety. Therapist incorporated behavioral therapy to assist client with the
causes of anxiety. During this session the client was observed engaging in cognitive therapy, which
entailed therapist assigning activities that helped change client thoughts and beliefs that triggered client
fear of anxiety. The client was asked to challenge her emotions and note times client thought negative
and jotted down how the physical body responded. The client successfully accomplished the exercise.
ivy4: During the last session, Client had difficulties with restlessness and played with
her fingers and tiny toys. In the process, play therapy had to be involved to boost client concentration
during the session. This approach led to reduced tension. Client restlessness and anxiety revealed that
client had little progress following the last meeting’s treatment plans. This is even though client had
observed all the requirements, which included integration into society, making new friends, and
accomplishing the prescribed exercise. Therapist encouraged the client to engage in mindfulness,
relaxation practices, client was willing to attempt and mentioned meditating as one of her favorite
practices. Therapist also encouraged client to exercise during gym at school to build self-confidence and
self-esteem and continuing to utilizing breathing techniques to help calm her emotions. Going forward, this
therapist plan to incorporate interpersonal therapy, cognitive therapy, exposure therapy and structured
problem solving during next sessions.
ivy5: At the time of this session, client presented anxious and expressed excitement
for the holiday weekend, client would spend with family. Therapist was able to engage with client and
allowed client to continue to express excitement. Throughout the session, client expressed areas that
required improvement in regard to receiving poor grades, Therapist was able to approach the session with
an CBT lesson. The treatment plan involved completing an ABC of CBT worksheet, client had to identify
every important assignment that was approaching and express her thoughts about that upcoming
assignment and explain consequences with failure to fulfill those commitments. Client also had to write
down what emotions would be felt if those commitments were not met and the consequences that could be
faced. Client was receptive and able to complete exercises with therapist.
Robert2: At the time of this session, client described feeling overwhelmed by school work
and that client felt himself slipping behind. The contributing factors were due to client having issues with
the thoughts of losing his parents at such a young age. Client explained feeling fearful when meeting
people and getting attached to them. The therapist noted that the client emotional state appeared panicky
and agitated, client rocked legs and could not stop moving fingers that were in front of client chest. During
the session the therapist focused on helping the client expand on problem solving capacitates: and
emphasized on helping the client develop greater trust in the therapeutic setting. The ongoing treatment
plan includes grief counseling, addressing problematic coping strategies, supportive assistance and crisis
management.
Robert 3: At the time of this session, therapist questioned client on well-being, client
denied feeling overwhelmed at this moment, client has decided to dedicate more spare to complete
homework assignments. Client self-care practices has increased, client mentioned praying and meditation
to help keep the mind focused. Therapist continues to encourage client to exercise daily to maintain his
mood, Client encouraged to continue religious and spiritual practices.
Robert 4: Therapist encouraged client to discuss current emotions since returning home
from hospital and/or what led up to hospitalization. Client reported the events that client believed led to
hospitalization which were feeling alone, client stated disliking the feeling of isolation. At the time, client felt
depressed about his current life and client began to experience death thoughts while at school, when he is
isolated the most due to lack of social skills and friendships. Client feelings of depression led to suicidal
tendencies, which revealed that gradual subjection to exposure therapy was necessary to achieve during
this session with therapist. Therapist encouraged client to exercise daily to improve his mood, since client
mentioned working out is something that is enjoyable. Client encouraged to attempt building friendly
relationship with others while in school along with maintaining those healthy relationships and boundaries.

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