Psychotherapy Progress Note

Patient Presentation: [Provide a detailed description of the patient's primary mental health concerns and their impact on daily life. Include information about: - Mental status (e.g. mood, affect, orientation, speech) - Specific mental health issues (e.g. depression, anxiety, trauma, substance use) - Duration of symptoms - Self-medication behaviours (e.g. alcohol, cannabis, nyaope) - Emotional experiences (e.g. hopelessness, irritability, grief) - Functional effects on everyday life (e.g. challenges with work, school, parenting, relationships) - Risk assessment (e.g. suicidal ideation, self-harm, aggression, vulnerability)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Therapeutic Interventions: [List the therapeutic interventions used during the session, such as: - Psychoeducation using language and concepts relevant to the South African context - Cognitive reframing techniques tailored to local stressors (e.g. unemployment, family conflict, financial pressure) - Recommendations for support groups (e.g. community-based, NGO-run, church-affiliated) - Discussions about personal responsibility and coping within systemic challenges - Emotional awareness and regulation exercises - Strategies for reducing anxiety and stress (e.g. breathing, grounding, problem-solving) - Insight building responses (e.g. empathic reflections, culturally appropriate interpretations)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Progress Statement: [Summarize the patient's progress in various areas, including: - Improvements in targeted behaviours or symptoms - Ongoing challenges (e.g. lack of support, substance exposure, ongoing trauma) - Areas of growth (e.g. emotional awareness, help-seeking) - Aspects requiring further work - Development of insight (e.g. increased self-reflection) - Description of developing themes (e.g. identity, grief, resilience, conflict resolution)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Patient Response: [Describe the patient’s response to the therapy session, including: - Reaction to interventions (e.g. openness, resistance, relief) - Changes in thinking or perspective - Implementation of strategies between sessions - Emotional state after the session (e.g. calmer, tearful, motivated)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)