DARP note

DARP 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. He reported feeling overwhelmed with work and personal responsibilities. His mental status was alert and oriented, but he appeared fatigued and had poor eye contact. Interventions included cognitive-behavioural techniques to address negative thought patterns and guided relaxation exercises. John responded positively to the relaxation exercises but struggled with cognitive restructuring. Assessment tools indicated moderate levels of anxiety and mild depression. Assessment: John's current diagnosis remains Generalised Anxiety Disorder and Major Depressive Disorder. There are no changes to his diagnosis at this time. He denied any self-harm, suicidal, or homicidal thoughts. John is making slow but steady progress towards his treatment goals, though his anxiety levels remain a significant area of concern. Continued focus on cognitive-behavioural strategies is recommended. Response: John responded well to the relaxation exercises, reporting a temporary decrease in anxiety. However, he found it challenging to engage fully with cognitive restructuring techniques. He expressed a desire to continue working on these strategies and showed motivation to improve his mental health. Plan: The treatment plan includes continued use of cognitive-behavioural techniques and relaxation exercises. John is assigned homework to practice these techniques daily and to keep a journal of his thoughts and feelings. A referral to a support group for individuals with anxiety is recommended. The next session is scheduled for October 12, 2023, at 10:00 AM in Dr. Kelly's office.