Ontwikkelingsrapport Raadgever
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Zakelijk Notitie tijd vooruitgang Cliënt Handtekening Datum
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STAFF SIGNATURE LPC CREDENTIAL 3/12/10 DATE SUPERVISOR SIGNATURE (If Applicable) CREDENTIAL DATE Conversion chart: March 2010 Greater Cincinnati Behavioral Health Services Counseling Progress Note Affix CLIENT label Client Name: Client ID: Staff Name: Staff ID: Affix STAFF label Date of Service □ am □ pm Start Time M M Program: Client Location (check only one) D CTU D Y Y Counseling Y □ am □ pm End Time Y □HE-face-to- face □ HQ-group □ 51-Summit □09-Incarcerated □ UK- client not present Service Code: H0004 Team: □ 53-GCB □ 12-Client Home □ 99-Community in group Date entered: Observed/Reported changes in condition: None Stressors/Extraordinary Events: None No significant change from last visit Client Condition casual and neat unkempt fastidious disheveled unusual/bizarre appears younger appears older apprehensive cooperative guarded aggressive passive agitated unusual/bizarre impulsive fearful dramatic other: clear coherent impoverished rapid flight of ideas incoherent fragmented disordered loose tangential other: Appearance appropriate inappropriate Behavior poor hygiene other: Stream of Thought Abnormalities of Thought Content none phobias concrete thinking paranoid ideation delusions overvalued ideas ideas of reference poverty of thought obsessions other: visual Perceptual Disturbances none depersonalization derealization auditory illusions tactile olfactory other: appropriate inappropriate expansive guilty bright congruent incongruent labile heightened depressed full range constricted blunted flat other: euthymia elevated euphoria angry/irritable apprehensive anxious depressed dysphoria apathetic other: not time not place not person adequate limited impaired faulty fair impaired poor grossly inadequate Affect Mood Orientation oriented x 3 In
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