DAP Note

DAP Progress Note Template Client/ID: John Doe Therapy Provider: Dr. Kieran McLeod Session Date: October 5, 2023 Start and Finish Time: 10:00 AM - 11:00 AM Data: John Doe presented with increased anxiety and depressive symptoms, reporting difficulty sleeping and a lack of appetite. He appeared disheveled and had poor hygiene. During the session, cognitive-behavioural therapy (CBT) techniques were employed to address negative thought patterns. John responded well to guided relaxation exercises but remained visibly distressed when discussing recent stressors, including job loss and relationship issues. The PHQ-9 screener indicated a moderate level of depression. Assessment: John's current diagnosis of Major Depressive Disorder remains unchanged. He denied any suicidal or homicidal thoughts. Progress towards treatment goals has been slow, with significant areas needing attention, particularly in managing anxiety and improving sleep hygiene. John’s engagement in therapy is positive, but his overall mental health status requires close monitoring. Plan: The treatment plan includes continuing CBT with a focus on anxiety management and sleep improvement. John was given homework to practice relaxation techniques daily and to keep a sleep diary. A referral to a sleep specialist was made to address ongoing insomnia. Key takeaways for John include recognising and challenging negative thoughts. The next session is scheduled for October 12, 2023, at 10:00 AM in the same location.