Ct will be able to limit depressive rumination about ...



TREATMENT PLAN (ADJUSTMENT DISORDER WITH DEPRESSION, SAMPLE)DATE:4/3/21DIAGNOSIS NAME AND CODE:F43.21 Adjustment Disorder with Depressed MoodMODALITY PLANNED (Individual, Couples, Family, Group) IndividualFREQUENCY/LENGTH OF SESSIONS PLANNED: Once weekly, 45 minutesESTIMATED LENGTH OF TREATMENT:6 monthsTREATMENT GOALS (symptom-focused) and OBJECTIVES (how will you measure goals were achieved?) Include the words “as measured by” in objectives. Should be Specific, Measurable, Relevant to Diagnosis, and Medically-Necessary.LONG-TERM GOAL #1:Reduce overall frequency, intensity and duration of episodes of depression and grief related to breakup with partner, so that functioning is no longer impairedTARGET DATE:10/3/21Short-Term Objective 1: Ct will be able to limit depressive rumination about relationship to scheduled times daily, and not text ex-partner. Will learn and be practicing at least 2 self-care techniques when depression spikes above level 5, on scale of 1-10, with 10 highest, as reported by clientEstimated Completion Date, Objective #1:6/3/21Short-Term Objective 2: Number of days depression spikes will reduce to less than once weekly, and will average no longer than 2 hours, and client will self-report they are less severeEstimated Completion Date, Objective #2:7/3/21LONG-TERM GOAL #2:Client will be reporting reduction in frequency of insomnia and increased hours of sleep (currently takes over an hour to fall asleep, averaging less than 5 hours of sleep nightly)TARGET DATE:7/3/21Short-Term Objective 1:Ct will learn and report utilizing at least two tools nightly to improve sleep and nightly routine / better sleep hygiene Estimated Completion Date, Objective #1:7/3/21Short-Term Objective 2:Ct. will be reporting taking less than 30 minutes to fall asleep, and sleeping a minimum of 7 hours nightlyEstimated Completion Date, Objective #2:7/3/21INTERVENTIONS PLANNED (make as client-centered as possible)Periodically administer questionnaire(s) to assess symptoms, monitor progress, and monitor effectiveness of treatment; name questionnaire(s): Anger Management Training (describe):XCBT/ Help ct. identify distorted thinking/black and white thinking; Cognitive Restructuring, particularly around feelings of failure related to breakupAssertiveness/ Communication Skills Training (describe)Coordinate care Teach conflict-reduction techniques (describe):Couples or Family therapy to help therapist with assessment/diagnosis, to identify relationship dynamics that might be contributing to client symptoms, and help significant other(s) respond more effectively to client symptomsCrisis Intervention / Create safety plan (describe):DBT -- teach distress tolerance skills (describe)Substance Use/Other Addiction Counseling: Help client identify triggers, develop ways to cope with urges; Relapse Prevention (details):EMDR aimed at (be specific):XGrief/Trauma-Resolution Treatment (describe): Educate client about normal stages of grief related to relationship lossXHelp ct. identify / overcome obstacles to building/maintaining support system after loss of primary relationshipAssign reading/writing (describe/name): XHelp client create self-care plan related to depression (details): Including exercising, hobbies, healthy eating, listening to music, helping ct. identify things that still bring pleasureHelp ct. identify codependent behavior, and to identify/set desired boundaries (describe)Have client keep journal to increase awareness ofTeach Mindfulness/Meditation for anxiety reductionMotivational Interviewing focused onPlay Therapy/Art Therapy (describe)Psychodynamic psychotherapy (focused on)Psychoeducation aboutRefer to Group/Other referrals (details):Refer for medical evaluation /medication evaluation (state which, say why): Teach client relaxation techniques: Breathing exercises, progressive relaxation, visualization, body scans, etc.Systematic Desensitization/Exposure Therapy (say more) XTake history of symptoms/dysfunctional behavior/relationships. Help ct. identify conflicts from the past that form basis of current symptoms and unhelpful repetitive behaviors. Identify unconscious motivations, and secondary gainsAssist client in strengthening decision-making and problem-solving skills (describe):Teach coping skills for when ct is. emotionally dysregulated (describe):XTeach techniques to improve sleep (describe): Progressive relaxation, Sleep CDs, Calm App sleep storiesHomework assignments/Other:XOther: "Scheduled obsessing" -- having client limit ruminations and negative thinking to certain times during dayOTHER INTERVENTIONS/COMMENTS SPECIFIC TO CLIENT (if any): Therapist Signature:Thelma Therapist, LMFTDate Created:4/3/21Client Signature:John JonesDate Reviewed with Client(s):4/11/212nd Client signature, if applicable:TREATMENT PLAN UPDATE (ADJ. DISORDER W/DEPRESSION, SAMPLE)DATE: 7/3/21PROGRESS TOWARD GOAL #1: AttemptingPartly AchievedAchieved, Needs MaintenanceResolvedWorseningXAs Evidenced By:Ct is reporting episodes of depression that are less frequent, shorter, and less severe NEW TARGET DATE:10/3/21Progress To Objective 1: AttemptingPartly AchievedAchieved, Needs MaintenanceResolvedWorseningXAs Evidenced By:Client reports decrease in number of times he has texted his ex-, but was not able to stop completely. Has learned and is using 2 items from self-care plan (exercise and music) when depressed, but at least weekly feels too depressed to implement self-care plan. Still reports difficulty limiting depressive rumination to scheduled times during the day, but it has lessened.Estimated Completion Date:10/3/21Progress to Objective 2: AttemptingPartly AchievedAchieved, Needs MaintenanceResolvedWorseningXAs Evidenced By: Number of days depression has reduced, and are less severe, but still occur at least twice weekly, sometimes averages longer than 2 hours.Estimated Completion Date:10/3/21If Objective(s) Achieved/ Resolved, is there New Objective for Goal #1?New Short-Term Objective Estimated Completion Date:PROGRESS TOWARD GOAL #2: AttemptingPartly AchievedAchieved, Needs MaintenanceResolvedWorseningXAs Evidenced By:Ct reports some improvement in overall sleeping hours and how long it takes to fall asleepNEW TARGET DATE:10/3/21Progress To Objective 1: AttemptingPartly AchievedAchieved, Needs MaintenanceResolvedWorseningXAs Evidenced By:Ct reports using better bedtime routine, progressive relaxation and the Calm app nightly to help sleep. Estimated Completion Date:10/3/21Progress to Objective 2: AttemptingPartly AchievedAchieved, Needs MaintenanceResolvedWorseningXAs Evidenced By: Ct. states it still takes longer than 30 minutes to fall asleep, and averaging only 6 hours nightlyEstimated Completion Date:10/3/21If Objective(s) Resolved/ Achieved, is there New Objective for Goal #2?New Short-Term Objective Estimated Completion Date:IF NEW GOALS BEING ADDED, ENTER BELOW, with OBJECTIVES. OTHERWISE SKIP SECTIONNEW LONG-TERM GOAL (OPTIONAL):TARGET DATE:Short-Term Objective 1: Estimated Completion Date, Objective #1:Short-Term Objective 2:Estimated Completion Date, Objective #2:TREATMENT PLAN ADJUSTMENTS NEEDED? (choose one):XContinue plan without adjustments, ORContinue plan with adjustments (name adjustments, ex. new interventions): TYPE /FREQUENCY/DURATION OF SESSIONS:Individual, weekly, 45 minuteNEW ESTIMATED DATE OF THERAPY COMPLETION:10/3/21Therapist Signature:Thelma Therapist, LMFTDate Created:7/3/21Client Signature:John JonesDate Reviewed with Client(s):7/11/212nd Client signature, if applicable: ................
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