Name: Judy A.

Sample
1/26/2016

ID: 1
Page #: 1

SSN: 555-55-5555

Birthday: 7/7/1946

Date:

Session Data Report

Name: Judy A. Sample

Date: 1/26/2016

Diagnosis:
Axis I

300.02

Generalized Anxiety Disorder

Axis II

V71.09

No Diagnosis

Sessions:
Session

Date: 8/7/2006
Time: 9:00 AM to 10:00 AM
Modality: Individual Psychotherapy
Narrative Progress Note:
1

(60 min)

Progress Rating: Some Progress

CPT Code:

Judy has shared her symptoms of anxiety. She experinces worry surrounding her safety but cannot explain why she should feel
so threatened. She is afraid to make many decisons as she fears some dire consequence. She is tense and feels nauseous often.

Session

Date: 8/14/2006
Time: 9:00 AM to 10:00 AM (60 min)
Progress Rating:
Modality: Individual Psychotherapy
CPT Code:
Problem Addressed: Anxiety
Patient Presentation (Signs and Symptoms):
The client related that she is constantly feeling on edge, that sleep is interrupted, and that concentration is difficult.
The client described a history of restlessness, tiredness, muscle tension, and shaking.
The client reported the presence of symptoms such as heart palpitations, dry mouth, tightness in the throat, and some shortness of
breath.
Interventions Implemented:
The client was taught about how anxious fears are maintained by a cycle of unwarranted fear and avoidance that precludes
positive, corrective experiences with the feared object or situation.
A discussion was held about how treatment targets worry, anxiety symptoms, and avoidance to help the client manage worry
effectively.
2

Problem Addressed: Chronic Pain

Patient Presentation (Signs and Symptoms):
The client has complained of pain throughout her body and in many joints, muscles, and bones.
The client has significantly decreased or stopped activities related to work, household chores, socialization, exercise, and sexual
pleasure because of pain.
The client made frequent pessimistic verbalizations about her inability to control the pain or live a normal life or be understood
by others.
Interventions Implemented:
A history of the client's experience of chronic pain and her associated medical conditions was gathered.
The changes in the client's social, vocational, familial, and intimate life that have occurred in reaction to her pain were explored.
Narrative Progress Note:
Session

Date: 8/23/2006
Time: 9:00 AM to 9:30 AM
Modality: Individual Psychotherapy
Narrative Progress Note:
3

(30 min)

Progress Rating: No Change

CPT Code: