Client Name: John Doe
Date: 1 November 2024
Preparation Phase Completed: Yes
Presenting Issue or Memory
Image:
- Most Disturbing Image: A car accident scene with broken glass and blood
Negative Cognition:
- Negative Cognition: I am powerless
Positive Cognition:
- Positive Cognition: I am in control of my life
Validity of Cognition (VoC):
- VoC Rating: 3
Emotions:
- Emotions Experienced: Fear, anxiety, helplessness
SUDs:
- SUDs Rating: 8
Location of Body Sensation:
- Body Sensation: Tightness in the chest
Desensitize:
- Desensitization Process: Eye movements were used, and the client reported a decrease in anxiety
Processing and Checking for New Channels:
- Processing Notes: New memories of the hospital visit emerged, causing distress
Installation:
- Positive Cognition Validation: The client rated the positive cognition as a 5 after installation
- Installation Process: Reinforced the belief of being in control through visualization exercises
Body Scan:
- Body Scan Results: Noted tension in shoulders, which was addressed with deep breathing
Procedure for Closing an Incomplete Session:
- Incomplete Session Notes: N/A
- Containment Exercise: N/A
Closure:
- Debriefing the Experience: Discussed the reduction in anxiety and new insights about control
- Future Work: Plan to address hospital-related memories in the next session
Notes:
- Observations or Issues for Future Sessions: Focus on building self-efficacy and addressing hospital trauma
Client Name: [Enter Client Name] (only include if explicitly mentioned in the consultation or medical records)
Date: [Enter Date] (only include if explicitly mentioned in the consultation or medical records)
Preparation Phase Completed: [Yes/No] (only include if this phase has been completed and documented)
Presenting Issue or Memory
Image:
- Most Disturbing Image: [Enter Most Disturbing Image] (only include if explicitly mentioned, describe the most disturbing image or picture that represents the worst part of the incident)
- If No Picture: [Enter Image Description] (only include if no specific image is identified, provide a description of what the client thinks of when recalling the incident)
Negative Cognition:
- Negative Cognition: [Enter Negative Cognition] (list the negative belief the client holds about themselves in relation to the incident, as reported by the client)
Positive Cognition:
- Positive Cognition: [Enter Positive Cognition] (list the desired positive belief the client would like to have about themselves in relation to the incident)
Validity of Cognition (VoC):
- VoC Rating: [Enter VoC Rating] (use a scale from 1 to 7, where 1 is completely false and 7 is completely true, to rate how true the positive cognition feels to the client)
Emotions:
- Emotions Experienced: [Enter Emotions Experienced] (describe the emotions the client is feeling when they think of the incident and the associated negative cognition)
SUDs:
- SUDs Rating: [Enter SUDs Rating] (use a scale from 0 to 10, where 0 is no disturbance and 10 is the highest disturbance, to rate how disturbing the incident feels to the client)
Location of Body Sensation:
- Body Sensation: [Enter Body Sensation Description] (describe where the client feels the emotion or disturbance in their body, as reported by the client)
Desensitize:
- Desensitization Process: [Enter Desensitization Notes] (only include if desensitization process was carried out, describe the eye movements, tactile sensations, or sounds used, and any new observations or changes reported by the client)
Processing and Checking for New Channels:
- Processing Notes: [Enter Processing Notes] (only include if there are new disturbing materials coming up during processing, describe any new information or changes the client reports)
Installation:
- Positive Cognition Validation: [Enter Positive Cognition Validation] (only include if the installation process occurs, describe how the client validates the positive cognition with the incident or memory, including the rating scale from 1 to 7)
- Installation Process: [Enter Installation Notes] (only include if installation is done, include any steps taken to strengthen the positive cognition and ensure it becomes more adaptive)
Body Scan:
- Body Scan Results: [Enter Body Scan Results] (only include if a body scan was performed, describe any sensations or tension the client reports, and the actions taken based on the body scan)
Procedure for Closing an Incomplete Session:
- Incomplete Session Notes: [Enter Incomplete Session Notes] (only include if the session was incomplete, describe the steps taken to close the session, including encouragement, relaxation exercises, and client feedback)
- Containment Exercise: [Enter Containment Exercise] (only include if containment exercises were done, describe the relaxation or grounding exercise used before closing the session)
Closure:
- Debriefing the Experience: [Enter Debriefing Notes] (only include if closure was done, describe the debriefing conversation with the client regarding any new insights, thoughts, memories, or emotions)
- Future Work: [Enter Future Session Notes] (only include if future work or goals are discussed, describe any future topics, goals, or issues to be addressed in subsequent sessions)
Notes:
- Observations or Issues for Future Sessions: [Enter Notes and Observations] (only include if there are specific observations, issues, or goals for future sessions that need to be noted)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
