A statement about the client's commitment and adherence to the treatment plan may be included in which portion of the case notes?
a. Current Plan
b. Current Assessment
c. Subjective Report
d. Clinician Observations
Q. 2The Clinician Observations portion of a case note includes therapist observations of:
a. client functioning in the session.
b. apparent changes in thinking.
c. client appearance.
d. how the client relates to the counselor.
e. Two of the above
f. Three of the above
g. All of the above
Q. 3The Subjective Client Report portion of a case note should be:
a. a verbatim record of the client's self-report of changes in thoughts, mood, etc.
b. a brief summary of the client's report of changes in thoughts, mood, etc.
c. a brief summary of the client's report of changes in different settings.
d. a verbatim summary of the client's report of changes in different settings.
e. a or d
f. b or c
g. Any of the above
Q. 4Case notes are written after which types of clinical contacts?
a. individual counseling sessions
b. group counseling sessions
c. phone contacts
d. Both a and b
e. All of the above
Q. 5Case notes, or progress notes, are always tied to the:
a. intake summary.
b. termination summary.
c. mental status exam.
d. treatment plan.
Q. 6Referring the case example of Sienna, the counselor wrote the following information in the intake summary: a problematic pattern of psycho-emotional and attitudinal dependence.. This information most likely was recorded under:
a. Mental Status Exam
b. Background, Family, and Relevant History
c. Presenting Concerns
d. Identifying Information
e. Goals for Counseling and Course of Counseling To Date
Q. 7This section of the Intake Summary may include the need for further assessment, referral, or consultation:
a. Mental Status Exam
b. Background, Family, and Relevant History
c. Presenting Concerns
d. Identifying Information
e. Goals for Counseling and Course of Counseling To Date
Q. 8This section of the Intake Summary provides a short two or three sentence overview of the client and summarizes basic demographics:
a. Mental Status Exam
b. Background, Family, and Relevant History
c. Presenting Concerns
d. Identifying Information
e. Goals for Counseling and Course of Counseling To Date
Q. 9Information on record and Psychological testing results are two forms of:
a. diagnosis and treatment planning notes.
b. case notes.
c. initial contact information.
d. treatment planning notes.
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