Play Therapy Note

Client Information: - Client Name: Emily Johnson - Provider Name: Dr. Thomas Kelly - Date of Service: 1 November 2024 - Session Duration: 45 minutes SUBJECTIVE Presentation: - Chief Complaint: Difficulty in expressing emotions and social withdrawal OBJECTIVE - Type Of Play: Sand tray therapy - Materials Used: Sand, miniature figures, and toy animals - Play Narrative And Symbolic Themes: Emily created a scene with a castle surrounded by animals, symbolizing a desire for protection and companionship. ASSESSMENT Progress And Response: - Response To Treatment: Emily appeared more relaxed and engaged during the session. - Specific Examples Or Instances: She initiated play with the therapist, which is a positive sign of trust. - Challenges To Progress: Emily occasionally hesitated to express her feelings verbally. - Therapist Observations And Reflections: The play indicated a need for security and connection, which aligns with her social withdrawal. PLAN Discussed Goals: - Goal 1: - Goal Description: Enhance emotional expression through play - Metrics: Increased verbalization of feelings during sessions - Attainability: Achievable with consistent sessions - Relevance: Important for improving social interactions - Time Frame: 3 months - Quote (Goal): "I want Emily to feel safe to talk about her feelings," said her mother. - Barriers To Achieving Goals: Emily's initial reluctance to open up Follow Up Actions And Plans: - Homework: Encourage Emily to play with peers at home - Plan For Future Session: Introduce role-playing games to explore emotions - Plans For Continued Treatment: Weekly sessions to maintain progress - Coordination Of Care: Communicate with Emily's school counselor to support her social development