Trauma Therapy Progress Note

Symptoms/Orientation (check boxes)

Alert

Good hygiene

Poor hygiene

withdrawn

constricted affect

blunted affect

flat affect

labile mood

sleep problems: difficult falling or staying asleep

sleep problems: sleeping too much

sleep problems: nightmares

appetite changes

problem concentrating

cheerful

proud

excited

tired

fatigue

sad mood

grief/loss

hopeless

helpless

shame
lonely

guilt

Angry

Frustrated

Hopeful

Overwhelmed

anxious

worry

fearful/scared

obsessive thoughts

irritable

avoidant bx

dissociation

life apathetic

^ death thoughts

recent self harm

grandiosity

rapid speech

racing thoughts

distractibility

^ goal directed bx

^ risk taking bx

^ impulsive bx

tearful

Restless
Animated

Low motivation

Persistent negative thoughts

Stress/external stressors

No satisfaction in pleasurable activities

Avoiding eye contact

Good eye contact

Intense eye contact

High energy

Low energy

steady, even energy

Medication Changes (empty field)

Interventions (check boxes)

active listening
reflecting thoughts
ID emotions
Building rapport 
skills/resourcing
ACT: mindfulness
ACT: acceptance
ACT: self as context/perspective taking
ACT: defusion
ACT: identifying values
ACT: committed action
meditation
EMDR
EMDR: identifying targets
EMDR: bilateral stimulation
EMDR: peaceful place
EMDR: containment
EMDR: two-handed interweave
Ego States
SE: Orienting
SE: Observe & describe somatic experience
SE: noticing sensation
SE: noticing images
 SE: noticing behaviors
SE: noticing affect
SE: making meaning
DBT
DBT: distress tolerance skills
DBT: emotion regulation skills
DBT: interpersonal effectiveness skills
DBT: behavior chain analysis
Reframing
Safety planning
SandTray
Play therapy
Psychoeducation
Polyvagal theory
Window of Tolerance
Gottman-Rapoport method
Gottman: antidote to criticism, defensiveness, contempt or stonewalling
Gottman: dreams within conflict
Gottman: love maps, building friendship
Non-Violent Communication: needs under feelings

Client Summary (usually a direct quote from client)

Response (empty box: I type 4-5 sentences of content)

Plan