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Note examples

Examples below are based on a fictitious session to demonstrate SOAP, DAP, and GIRP progress notes created with CraftyNotes.

SOAP Note

Subjective:

  • The client expresses longing for a committed relationship involving marriage and children.
  • Describes feeling an urge to flee when potential for a relationship arises: "I make a unilateral decision a lot. Like I've got to get out of here."
  • Client idealized a long-distance partner as "the man of my dreams."
  • Acknowledges a pattern of rushing into decisions in relationships without fully assessing situations.
  • Conveys impulsive decision-making tendencies, particularly in the context of romantic relationships.
  • The client exhibits awareness of the urgency she feels due to age and witnessing peers having established families.
  • Communicated an experience of loss (passing of a family member) and an ongoing need to grieve.
  • Describes previous experiences of emotional presence in a long-distance relationship, which changed when living together.
  • Reports recent illness, integration issues with family, and acknowledgment of neglecting responsibilities.
  • Client's decision to leave was abrupt and communicated via text.
  • Client and partner are currently in occasional contact, mostly exchanging texts about daily happenings.

Objective:

  • Client attended the session and engaged in reflective discussion.
  • Demonstrates insight into recurrent patterns of behavior in relationships.
  • Shows understanding of the discrepancies between desires and actions.
  • Displays a range of emotional responses when discussing the relationship.
  • Nonverbal communication: nodding when discussing rushing into a close relationship for safety and fulfillment.
  • Openly discussing patterns in relationships and seeking understanding of said patterns with therapist assistance.

Assessment:

  • The client presents with a pattern of impulsive decision-making in romantic relationships.
  • There is an apparent discrepancy between relationship desires and actions, aligning with possible avoidance tendencies.
  • The client struggles with processing grief associated with loss, which may be influencing current relationship dynamics.
  • She exhibits an awareness of a need to break repeating patterns in relationships but has yet to develop strategies to do so.
  • Feelings of urgency related to age and social comparisons contribute to the pressure she feels to rush significant life decisions.

Plan:

  • Continue to explore patterns in relationships and their underlying motivations.
  • Develop strategies to manage impulsive decision-making, possibly through cognitive-behavioral techniques or mindfulness-based approaches.
  • Address grief and loss issues to understand their impact on current relationship choices.
  • Work on communication skills within the context of the client's relationship, emphasizing the importance of direct, open discussions about needs and concerns.
  • Encourage client to reflect on expectations of marriage and how they align with personal goals and identity.
  • Consider couples therapy to address communication issues, togetherness, independence, and family integration challenges if both are willing to engage.

Impairments and Challenges:

  • Difficulty with managing impulses to flee when faced with potential relationship commitment.
  • Tendency to idealize partners and rush into significant life decisions without thorough consideration.
  • Struggle with reconciling a strong desire for a long-term relationship with avoidant decision-making tendencies.
  • Dealing with unresolved grief that may be influencing relationship choices and expectations.
  • Challenges integrating into the family and adjusting to living together.
  • Potential issues with communication and expressing needs in the relationship.

Sun, 07 Apr 2024 12:41:27 GMT

DAP Note

Client's Description:

  • Expresses longing for a committed relationship involving marriage and children.
  • Describes feeling an urge to flee when potential for a relationship arises.
  • Idealized a long-distance partner as "the man of my dreams."
  • Acknowledges a pattern of rushing into decisions in relationships without fully assessing situations.
  • Conveys impulsive decision-making tendencies, particularly in romantic relationships.
  • Expresses awareness of urgency due to age and social comparisons.
  • Communicated an experience of loss and ongoing need to grieve.
  • Describes previous experiences of emotional presence in a long-distance relationship.
  • Reports partner’s recent illness, integration issues with family, and acknowledgment of neglecting responsibilities.
  • Decision to leave partner was abrupt and communicated via text.
  • Currently in occasional contact with partner, mostly exchanging texts about daily happenings.

Therapist's Observation:

  • Client attended session and engaged in reflective discussion.
  • Demonstrates insight into recurrent behavior patterns in relationships.
  • Shows understanding of discrepancies between desires and actions.
  • Displays a range of emotional responses when discussing relationship.
  • Nonverbal communication indicates agreement when discussing rushing into relationships.
  • Openly discusses patterns in relationships and seeks understanding with therapist assistance.

Assessment:

  • Presents with a pattern of impulsive decision-making in romantic relationships.
  • Apparent discrepancy between relationship desires and actions, aligning with possible avoidance tendencies.
  • Struggles with processing grief associated with mother's death, impacting current relationship dynamics.
  • Awareness of need to break repeating patterns in relationships, but yet to develop strategies to do so.
  • Feelings of urgency related to age and social comparisons contribute to pressure to rush life decisions.

Plan:

  • Continue exploring patterns in relationships and their underlying motivations.
  • Develop strategies to manage impulsive decision-making, possibly through cognitive-behavioral techniques or mindfulness.
  • Address grief and loss issues to understand impact on current relationship choices.
  • Work on communication skills within relationship, emphasizing importance of direct, open discussions.
  • Encourage reflection on expectations of marriage and alignment with personal goals.
  • Consider couples therapy to address communication issues, togetherness, and family integration challenges if both willing.

Impairments and Recommendations:

  • Difficulty managing impulses to flee when faced with potential relationship commitment.
  • Tendency to idealize partners and rush into significant life decisions without thorough consideration.
  • Struggle reconciling desire for long-term relationship with avoidant decision-making tendencies.
  • Dealing with unresolved grief that may be influencing relationship choices and expectations.
  • Challenges integrating into partner's family and adjusting to living together.
  • Potential issues with communication and expressing needs in the relationship.

Sun, 07 Apr 2024 12:41:27 GMT

GIRP Note

General Observation:

  • The client expresses a desire for a committed relationship involving marriage and children.
  • Describes feeling an urge to flee when potential for a relationship arises, indicating a tendency towards avoidance behaviors.
  • Client idealized a long-distance partner as meeting her expectations of an ideal partner.
  • Acknowledges a pattern of rushing into decisions in relationships without fully assessing situations, suggesting impulsivity.
  • Conveys impulsive decision-making tendencies, particularly in the context of romantic relationships.
  • The client exhibits awareness of the urgency she feels due to age and social comparisons, which may contribute to relationship pressures.
  • Communicated an experience of loss and an ongoing need to grieve, which could impact current relationship dynamics.
  • Describes previous experiences of emotional presence in a long-distance relationship, contrasting with current challenges in the relationship.
  • Reports recent illness, integration issues with family, and acknowledgment of neglecting responsibilities, indicating external stressors.
  • Client's decision to leave was abrupt and communicated via text, highlighting difficulties in direct communication.
  • Client and partner are currently in occasional contact, mostly exchanging texts about daily happenings, indicating a lack of resolution in the relationship.

Reflections and Insights:

  • Client demonstrates insight into recurrent patterns of behavior in relationships.
  • Shows understanding of the discrepancies between desires and actions, indicating potential for self-reflection and growth.
  • Displays a range of emotional responses when discussing the relationship, suggesting underlying emotional complexities.
  • Openly discussing patterns in relationships and seeking understanding of said patterns with therapist assistance, showing receptiveness to therapy.

Plan:

  • Continue to explore patterns in relationships and their underlying motivations.
  • Develop strategies to manage impulsive decision-making, possibly through cognitive-behavioral techniques or mindfulness-based approaches.
  • Address grief and loss issues to understand their impact on current relationship choices.
  • Work on communication skills within the context of the client's relationship, emphasizing the importance of direct, open discussions about needs and concerns.
  • Encourage client to reflect on expectations of marriage and how they align with personal goals and identity.
  • Consider couples therapy to address communication issues, togetherness, independence, and family integration challenges if both are willing to engage.

Challenges and Recommendations:

  • Difficulty with managing impulses to flee when faced with potential relationship commitment, requiring coping strategies.
  • Tendency to idealize partners and rush into significant life decisions without thorough consideration, necessitating reflection and self-awareness.
  • Struggle with reconciling a strong desire for a long-term relationship with avoidant decision-making tendencies, suggesting a need for therapeutic intervention.
  • Dealing with unresolved grief that may be influencing relationship choices and expectations, indicating a need for grief counseling.
  • Challenges integrating into the family and adjusting to living together, requiring support and guidance.
  • Potential issues with communication and expressing needs in the relationship, indicating a need for improved communication skills.

Sun, 07 Apr 2024 12:41:27 GMT

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