Treatment Progress Note

Students are expected to deliver a Treatment Progress Note detailing the experience of a counseling session. The Progress Note consists of two parts: a) the Formal Treatment Note and b) a summary of students’ Subjective Reporting. Formal Treatment Note should follow the DAP format, which equals to:

Description: The first part is to describe the client. Please, include age, race, ethnicity, occupation (professional, student, homemaker, etc.), a general description of appearance, and any significant other elements (such as a disability, unusual characteristics, etc.). Next, describe the presenting problem. This is the client’s reason for seeking counseling. Finally, indicate the location of the session, and the date and time. All the information in the description should be as objective as possible.
Assessment: This is student’s assessment of the presenting problem. He/she may simply be repeating what the client stated (such as with a client who tells you verbatim he is depressed). Or, he/she may be taking the content of what the client has stated and distilling it into a hypothesis. An example of this is indicating the “Client may be depressed and/or anxious” for someone reporting feeling sad, stressed out, and having trouble sleeping and who appears very nervous. Please, be careful with your wording. If you are not sure about the problem, use wording such as “it appears” or “client may be.” When unsure, you should include further assessment of the concerns in your treatment plan. If the student cannot comfortably make an assessment based on lack of information, he/she can state such.
Plan: This is student’s plan for future sessions. This can be a very simple statement reflecting future plans and should not replace the formal Treatment Plan. For example, the student may state “Need to further assess alcohol use” for someone appearing to have alcohol use issues.
Important note: Subjective Reporting consists of each student’s emotional and/or cognitive responses to the client (or the client’s situation) during the session……

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