Presenting Problem

Complex PTSD. Brutally beaten as a child. Did not remember it until than. He had deep depression and anxiety. He went to therapist on compus he had his first flashback. They are new materialy.

Identification:	54, white, single, no religion. His mo was a church con. He was a part of that at a young age. He learned to distrust churches and religion.
History of Present Problem:	He was depressed as a young kid. 1997 flashbacks of his parents severely abusing him. They attempted to kill him. In 1999 flashbacks of them killing and torturing others started. When the flashbacks start the anxiety and when they are active the depression kicks in.
Psychiatric History:	Only over the last three or four years. For a long time he thought abuse was normal. It wasn't until he realized his life was a crappy life. He lives in Farmersville east of Dallas. About a 30 minutes.
Trauma History:	His first memory was his mother suffcating him on the couch. She pinned him on his back with her knees on his chest, choking him. Normally, she would beat him into unconsiousness and throw him in the closet. He just thought it was a strange behavior. 3 years old. The sexual abuse has recently popped into his flashbacks. He was abused at birth until he was 18. He got the opportunity to go to college and he never went back home. He lived with his bio fa after college for a year. No physical with them since 1995. His parents tried to divorce three times. After his undergraduate degree they finally divorced for good. His mo and fa were criminals. They were involved in trafficing of Mexican women and selling. When they

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Not Assessed
Dress:	Not Assessed
Motor Activity:	Not Assessed
Interview Behavior:	Appropriate
Speech:	Verbose
Mood:	Dysphoric
Affect:	Congruent
Insight:	Excellent
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Biopsychosocial Assessment

	would go to Mexico he was behind the seat behind the seat. Auctions, bikers, all. They would put women in 50 gallon drums sealed. They would have barn parties where cowboys could rape them for a fee. He sat on a haystack while this went on. No one would bother him. The oldest bro is Mike. He was ten years older. He never lived in their house. He lived with the mo's cousin. He did not see him until he was 3. He was in the kitchen. His mo told him that was his bro. He would stay 3 days and be packed back off. His younger bro , Greg, was raised by baby sitters. He would come to the house for a few hours then the babysitter would return and he would disappear. His bio mo recently died. He got in touch with his bro's via text getting rid of ashes. His fa died ten years ago. He didn't learn about his death until 6 years after. There is a step mo named Mona. His parents were very criminal when he was young. After the divorce as he got older he was less abusive. His mo incestuous relationship with her younger bro. They would team up and go after others. Shoot people for money. Fraud. They never won a court case.
Family Psychiatric History:	None of them went to therapy or got diagnosed. He knows as a clinician. His fa was a multiple personality his mo was borderline with narcissistic traits. His older bro is a workaholic. His younger bro is learning disabiled and has a job working for the city.
Medical Conditions & History:	He's learning disabled. He has two TBI, reading and writing disabilities, discalclia. His IQ is 140. One time his IQ came out 98. If he's having flashbacks his IQ drops. He's written books for the FBI, Texas Rangers, etc. Cold cases that he had memory of that he believed happened in that area. He knows where the bodies are buried. He was there. The age of the girl, naked or not, position. Where they lived at the time. Many were undocumented women. The family had 21 residences but the majority was in Irving, TX. The detective, Barr, said he did not have the time to work the cases. The FBI and Texas Rangers investigated him. Pineville, LA. If he went there he would be arrested. He wouldn't talk with the cops so the neighbors harrassed. He went with his father in the boondocks. They were rural farm families. They would rob, rape, and murder them. His grandfa was a known rapist. He only raped Mexican women he was not put in jail. Whe he was young the family talked about it. His aunt and uncle participated. If young Mexican women came to the area they would call the grandfa and he would abduct them.
Current Medications:	Anxiety meds, panic pill - doesn't help, insomnia pill - more affective than the panic pill. The depression exhausts him. He will sleep for two or three days at a time. The anxiety and depression go away and he fees really good. He would be put into therapy by the school system. Sometimes there was a cop present. His mo was a teacher. Her friends would tell her parents and they would move. After that he would get severly beaten. He didn't know what happened. He was thrown in the back of the car and driven a long way.
Substance Use:	No addictions. He only used alcohol when the flashbacks first started he couldn't get meds. That lasted two years than he stopped.
Social History:	All the children he raised in foster care. He loves seeing them. He has one good friend. He is the ADA of Hunt County. His niece and nephew are grown. His bro talks about it some. His younger bro had two children and a wife but he doesn't know any of them.
Spiritual/Cultural Factors:	He has no cultural history but is a survivor. Just getting through the next day.
Developmental History:	Always in Resourc Special Education all through high school. He was in summer school every summer. His parents are both college educated. They believed if you were not college educated you're white trash. He liked college. He had to work two and three times then everyone. He was treated as being retarded. He behaved retarded. He dissociated.
Educational/Vocational History:	Master Social Worker, PTSD started in in the graduate program. He was acceptede in the phd programs but the flashbacks made it unmanageable. He accomplised the first semester. First school Texas tech, Univ of Texas Arlington, Sabor out of CA. 20 year career as a SW in psychiatric facilities. He is disabled and on disability.
Legal History:	Never.
SNAP:	Love of others. He loves his children not through the system but he worked through an agency and they allowed him to care for them. No money or services. He had one of his children for 15 years. Needs: He needs a new psychiatrist, a pain managment specialist, a dental appointment, Section 8 to pay the rent. He barely gets by on his disability. He pays all his bills. Gas and food. He sees his children all the time. He just got approved for 21 hours of care.
Other Important Information:	Most of his traumas he puts in his trauma, he journals and it goes away. The sexual abuse trauma won't go away. He's been a thx of 20. He's never recorded it, read about. He's not been able to talk about. What heals him is asking him questions helps him more than anything. He signed up for an Sex Abuse group but it doesn't start until August.

Plan

Learn coping techniques to reduce PTSD and prepare to handle future stressful situations (thought stopping, thought switching, creative visualization, progressive muscle relaxation, deep breathing, etc.); this is sometimes called “stress inoculation training”

Diagnosis

F33.1 Major Depressive Disorder, Recurrent episode, Moderate

Susan Colburn, LCSW, Licensed Clinical Social Worker, License 29704, signed this note and declared this information to be accurate and complete on 7/16/2024 at 12:09 ᴘᴍ.

Diagnosis

F33.1 Major Depressive Disorder, Recurrent episode, Moderate

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Not Assessed
Dress:	Not Assessed
Motor Activity:	Not Assessed
Interview Behavior:	Appropriate
Speech:	Verbose
Mood:	Dysphoric
Affect:	Congruent
Insight:	Excellent
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Anxiety meds, panic pill - doesn't help, insomnia pill - more affective than the panic pill. The depression exhausts him. He will sleep for two or three days at a time. The anxiety and depression go away and he fees really good. He would be put into therapy by the school system. Sometimes there was a cop present. His mo was a teacher. Her friends would tell her parents and they would move. After that he would get severely beaten. He didn't know what happened. He was thrown in the back of the car and driven a long way.

Subjective Report and Symptom Description

He had a flashback, he gets feelings of horror. He has journals going all the way to 1990. The psychiatrist he was seeing told him his dreams. He would tell the doctor his dreams. He made an appointment with a psychiatrist with whom he will meet tele. He remembered being an infant at his nona's. His mo came around the corner with a pot of boiling water. She planned to pour it on the baby. His nona stopped her. He went hunting with his fa and watched as his fa killed the fa and raped and killed his daughter and through them into the ravine. The flashback was triggered by screams of children. It was ice cold and his father and daughter were naked. His fa was on top of the girl strangling her. He gets different frames. He can't process the traumatic event until all the frames. It's when something will cross over and trigger a flashback. A sound, a smell, startle reflex. He feels a feeling in his stomach and knows a flashback is coming. When it first started he didn't talk about any of it. A thx he saw triggered his flashbacks. Him reading the details helps him to get past the trauma. Sometimes he will get stuck on a flashback. He will read his journal and those details trigger more details. More recently he would take his laptop and record his face while he was listening. One thx would not see him until he gave him a tape. With him he would have bouts and bouts of depression and couldn't get things processed out. He would hypnotise him. He was relaxed and able to receive images. The sexual abuse by his mother was so diabolical. He could deal with the strangling. He has raised over 50 foster children, worked as a thx, worked in criminal justice. He can't find a category for the sexual abuse of his mother. His fa would put a hangman's noose around a woman's neck and drag her around. He's afraid to fully open the flashback of his mother will open up more sexual abuse with his mother. The imagery processed out quickly but he doesn't know if he has all the details. In therapy he can talk about it because people get traumatized. Some of his thx have gotten traumatized and he has to leave them. His older and younger brothers made it very difficult. His mo would give him money when he visited. The money went for his care. His younger brother is a lot like his parents. They bonded with him. Bryan had feelings and emotions. He was placed in special education all through school. The dissociation would delay him developmentally. If he began to understand what was happening they would torture him and gaslight him until he would repeat what they told him to say. He would hyperventilate and they would kick him in the nuts, can't get air. When he became unconscious it was peaceful. He thought he was dead. They would put him in a closet, his bed, the piano room. Despair led to all the pain. The pain radiates, he couldn't cry, move, barely breath. He would have deficated and urinated in his pants. When he got an MRI the doctor wanted to know if he'd fallen off a building. He had two injuries to his brain that had healed. Later with good insurance with a good job. He was tested by a Psychologist. His brain is in every quadrant equally. This not supposed to be. From very highly intelligent all the way down to thinking impaired. The damage done to his brain doesn't show but the MRI shows proof he was abused. He didn't share this with his bio parents because they didn't care. His older brother being placed with a cousin. His mo would pull stunts like threaten to kill Bryan if he did not allow the older brother to visit. Two sociopaths playing games. When his father would do crimes he would take Bryan with him. Bryan witnessed a lot of murders, rapes, and tortures. He's not gone multiple. He developed an amenisic pocket. The flashbacks from 19971999 was of their abuse of him. In December 1999 he began to have flashbacks of his father's criminal acts. When he graduated college, 1999, he became severely depressed. He would sleep all day. He paid a hypnotherapist to put him under and ask him questions. A murder popped up. It occurred in a LA rental house. His fa had kicked his mo out telling her he didn't love her. He had a rondeveau with a teenage girl. Once she was naked he jumped on her and began strangling her. She understood that when he opened the door to the garage she would die if she went into the garage. She held on to the door frame and a fingernail and part of a finger was stuck in the door frame and in Bryan's his brain. She had fecal matter that came out and was green. It was like normal fecal matter but it was green like an alien. Eventually, his mo returned and the mo and fa went into the bedroom and left him, at 2 or 3 years old, in the kitchen, alone, cold. He climbed on the couch and slept. The next day they put the girl's body into the trunk of the car and took it to a property where there was a man made pond. It was supposed to rain the next day and fill the pond. His fa poured gasoline over the dead girl which burned until the body was black. Dec. 1999.

His fa worked on oil rigs. He was not a hard worker. He would pick fights, etc. and get fired. Many victims his mother chose were from her class that she wanted to torture. Many schools in Irving, descriptions, when they disappeared, a teacher student, Robert and Glenda always talked about divorce. Glenda would tell everyone. One lady, a big "Karen". She would insult and say mean things to Robert. When they reconciled Glenda told him about her. He took Bryan when he went to her house and abducted and murdered, beaten, put into the trunk unconscious, he beat her, raped her, while they were both naked. He choked her a few times until she went out. She would come back and he would jump on her again. He dragged her by the hair to the ravine and threw her in. Bryan contacted Detective Bah, of the Irving Police, and told him what happened. The detective told him no one wanted to work on the case or had time to work on it. This was in the '70's adults could leave whenever they wanted to. The last time she was seen was with his bio mom and to cops went to the school and tried to ask his mo questions until she got mad. She and Bryan got into the red station wagon, left the parking lot. She pulled over and was wailing and crying and hitting the steering wheel. The cops saw her and one came to the window to see if she was okay. She was cursing at them and telling them to get away. The cops also

Interventions Used

The following interventions were used: Interactive Feedback, Cognitive Reframing, Structured Problem Solving, Cognitive Refocusing, Exploration of Emotions, Guided Imagery, Cognitive Challenging, Exploration of Coping Patterns, Exploration of Relationship Patterns, Preventative Services, Supportive Reflection, Symptom Management, Interpersonal Resolutions, and Psycho-Education.

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

According to the ICD-11, complex PTSD results from exposure to a traumatic event or series of events of an extremely threatening nature. The events are usually prolonged or repetitive and escape from the situation is impossible or dangerous.

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

This therapy takes place with a trained, licensed mental health professional, such as a psychologist or psychiatrist. It can provide support, education and guidance to you and/or your loved ones to help you function better and increase your well-being.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Progressing

Plan

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Susan Colburn, LCSW, Licensed Clinical Social Worker, License 29704, signed this note and declared this information to be accurate and complete on 9/27/2024 at 1:02 ᴘᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Not Assessed
Dress:	Not Assessed
Motor Activity:	Not Assessed
Interview Behavior:	Appropriate
Speech:	Verbose
Mood:	Dysphoric
Affect:	Congruent
Insight:	Excellent
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Subjective Report and Symptom Description

Bad week. Flashbacks. Pain. New Victims. The last flashback has not played out because of the situation. When he was 5, his fa, Robert, was taking children back. Robert snatched her and threw her into the front seat of the car. Robert grabbed her and made it inside. Soon the front door opened and cops came in. His fa came into the kichen from the living room. He must have been in the garage with the little girl. Ten cops went through everything in the house but did not go upstairs. They did go through the garage. He told them to get out. He pushed them. Eventually he did leave the house. No one spoke to him. He sat on the couch throughout. Someone had given Glinda a ride to the house and she was mad at Robert. Then he took her to the garage. There was no noise. Glinda wanted to know how they would get rid of this body. They went into their bedroom. Bryan slept on the couch. There was no screams or crying he imagine he killed the girl very quickly. His parents were pack rats, hoarders, and there was a lot of places to hide a small body. Then they left. This was not the first or last time they were at the house. When he had the flashback, he called the police department. They said they didn't have time to deal with it. He didn't have that flashback until 2018. Yesterday, he had a flashback of another victim. Everytime he thinks it's the last one. It's like it never ends. It will never heal. He can't piece it together. He gets body aches and pain. A feeling of horrer and impending doom. That tells him that flashback hasn't processed it's way out. He has not been able to sleep. He hasn't slept for 48 hours. He has gone as long as 72 hours without sleep. His caretaker came today. He did not have her cook for him because he's not hungry. It's been eventful since the last session. He documented and typed up. The flashback called the Dorchester Barn, a hay barn. He used that barn to have his fa and an uncle to kidnap a person. His grandfa is with Bryan, a child. He became more and more aggressive. He masterbated 4 times. His fa and his uncle were bringing the woman into the barn. Bryan recognized her because of the ornamental hair pins. She had come to his grandparents house. She had the same hair pins, and shoes. She had pantyhose that were tan and lumpy. She still had those on when they brought her in. At the house in Sherman there was a sitting room. He was in the room playing. Glinda and Edith (grandmother) were listening to her talk about all the things a Christian woman should expect from a Christian man in marriage. The woman left. His mo and grandmo told Robert and Max about what the women told them. The men started punching them and put their foreheads on the table. Max and Robert were smacking them across the back of the necks and the tops of their heads. They were telling them not to tell a man how to act in his home. They hit the women until his mo begged him to stop. They stopped and immediately began fixing a meal. Bryan was put in the high chair and they ate dinner. The woman was kidnapped for insulting his fa and grandfa. They're every macho and intolerate disobedient women. His whole body aches. His back hurts most of all. He has a bad back when his muscles begin to tighten, his lower back more. Bryan's would do kidney and liver punches. His fa would sneak up on them and punch them in the liver and/or kidneys. His fa still to beat Bryan until he was 16. Bryan would tell him to get away. His little brother would attack the fa. The older and younger bros chose to fight the fa. Bryah ran away. His older and younger bros are similar to their fa. They're both very selfish and have things their way. They don't compromise. They both have children. His niece and nephew turned out very well. The younger bro's children stayed away from Bryan. His older brother divorced once. Than he married Mary Jo and is still married to her after 25 years. HIs older bro yelled and intimated but he doesn't know about anything else. He doesn't know about his younger brother. He is very happy his fa didn't make him out to be like him. Everytime Bryan would be in a romantic relationship it triggered depression. All he wanted was for them to go away and they would. Then he would get lonely and the same thing would happen. When his brain stops whirling he will fall to sleep and he may sleep 4-6 hours. He lives on his brother's farm and it's very quiet. He journal, when it pushes through and get the final parts of it. Then he is able to eat and sleep. Several of his children have PTSD. One dau has multiple personal disorder. He goes dissociate and than amnesia. His grandfa called him retarded. It was so bad that when he was in elementary school to use the bathroom. He would forget where he was and where his class was. The other children would let him know he was in the wrong room. When he got to the right classroom he had to find the empty seat to know where he was supposed to sit. He has two TBI's. A funny thing between he and his older brother. His mo died six months ago. She wanted to be cremated. He did not want his part of the ashes. His older brother came over and told him that they'd had the internment for their mo. He was visably sad. He lived outside the house and never say the abuse, violent behavior, the awfulness. Their mo gave Mike money whenever he needed it. The way she treated the boys. His mo was obsessed with family money. When his older boro was born she told him that made her part of the family permanently. She would be rich when his parents died. His fa and bro didn't get along. They had the same personality. The fa threatened to kill him. That's why he was sent to live with cousins. She would beat Bryan in front of him thinking he would give in and let his bro come home. When his fa would leave to do crimes the mo would make him take Bryan or she would kill him. He sounds like he has a cold but he says his throat is dry. It's an arduous task for him to get out of the chair and going to the kitchen to get water. It soothes him to go to the wafflehouse to journal. He watches the traffic and it calms him. At first he would panic and he couldn't get them on paper. This latest flashback caused him a lot of pain. He imagines the end of the woman who was kidnapped will be very gruesome and horrible. The whirling of his brain is beginning to calm down. For some reason he's recalling flashbacks from before, details of those events that have always been processed. This is the first real flashback he's had since we began working together. his mother had a lot of strange beliefs. She would buy holy ointment oils that she would buy at church revivals and that would heal them. Her fa's bro had three girls. Since his bro was the first male heir he would inherit more. The parents attempted divorce three times. The fa filed the fourth time and it was accomplished. His mo told an expensive law firm that his fa had 70 million dollars. When they found out the fa did not have 70 million dollars they dropped her.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Progressing

Plan

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Susan Colburn, LCSW, Licensed Clinical Social Worker, License 29704 signed this note and declared this information to be accurate and complete on 7/6/2024 at 9:28 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Not Assessed
Dress:	Not Assessed
Motor Activity:	Not Assessed
Interview Behavior:	Appropriate
Speech:	Verbose
Mood:	Dysphoric
Affect:	Congruent
Insight:	Excellent
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Subjective Report and Symptom Description

Brian wants me to call him Happy. He said he had a fruitful journaling period yesterday. He realized why his bio mo made him such a target. One time he went dove hunting with cousins. His father needed someone to watch Glinda. His father had all the kin employed in the store Glinda would get into arguments with her fa in the store as a child because she wanted him to fire people she was mad at. It elevated to adulthood.She kept the temper and demanding nature. He talked about a cousin who could only be mean with people. His mother was a teacher. She beat him viciously. If a girl liked him, she would get jealous. He would get beaten. That's a big part of the sexual abuse. She was always trying to seduce him. He would avoid her and she would get mad and attack him. If a teacher told his mo a girl in his class though he was cute it would send her into a rage. She beat him whenever she raged. She would taunt him and it kept him hypervigilant. As a small child he learned to hide in closets and under beds. He would move around during the night. Beatings would stop for weeks. Then she would find him and beat him. The beating happened more during the summer. That's when she took her drugs. She told doctors about asthma and her pain. The asthma drup were like speed. The pain meds were muscle relaxers and she would sleep for several days. On those days they didn't ear. One day she gave him one of her pills. His back was hurting or he was c/o pain. He laid on the couch and floated for hours. When the torture became too much and he wanted to die she would try to force feed him her pills. If he wanted to die she would help him, she said.

No matter how much she punished him to show Robert that she would kill him it was never enough. It opened him to seeing his fa's work:

sex slaver, kidnapper, and hit man.

They lived in rural TX, and family inheritances were of land and cattle. Sometimes there was oil on the land. People would hire his grandfather to kill their grandfather. A matriarch or patriarch would disappear. The inheritance would go to the children. They wanted their inheritance now. His bio. mo regulated her emotions by raging and attacking cousins or him.

His foster mom named him "Happy". He was never in regular Foster Care. It was a lady she met while in his 30's. Happy Smiles was a place where she worked, one of the day cares. He would volunteer and go to different places to cheer people. His pain comes and goes. Last week his pain level was very high. Sleep helps ease. His dad was a horrific person but when he worked or was killing people the focus was off Happy. His fa really loved his mo and wanted her to love him. She accepted the part of him that murdered, tortured, and kidnapped people. Both boys were neglected but the younger child wasn't beaten. He would get into physical fights with their fa. The bros have the fa's personality, including his older brother.

Happy went to grad school and read about Dr. Joe Max, who had passed away. He would ride a horse and care for farm families. His role modals were Johnny Carson and Mr. Rogers.They were both nice white man.When he heard the theme song for Johnny C. it was bedtime. His mo would go to bed and he would sneak downstairs and watch J.C.

Also Gilligan, from Gilligan's Island. (Window poem He would look ou the window and say Starlight....wish to get to go to Gilligan's Island.

He would be very nice to Gilligan. He also wished to go to Johnny Carson land. His role models were from TV shows: Johnny Cars,

Gilligan, Benny Hill, and Mr. Rogers

(He c/o tooth pain. He grinds his teeth. He is taking lots of Ibuprofen.)

One of his clinicians diagnosed him with amnesia, PTSD. Another clinician diagnosed him with Dissociative Disorder and Complex PTSD.

Happy says his personality has helped him survive. He was born with a happy go lucky personality. He doesn't hold on to resentment.

At UT Arlington, Dr. Eaves, and Dr. Bing were very kind. He knew he was a survive of abuse. In 1997 through 1999 her had flashbacks of abuse perpetrated on him. He was in Therapy on campus. He would dissociate in the office and have flashback. The therapist was frightened because of him. He didn't trust her although he said she was kind, caring and wonderful. She was a robotic clinician. She went through motions like a robot. She didn't engage emotionally. She didn't demonstrate sympathy or empathy. One day she asked him if he trusted her and he said no. She looked as though she wanted to cry which threw him because she never showed emotions.

He had no serious relationships. Romantic feelings trigger him and he isolates. The romantic feelings would trigger him. When her mother told him the teacher told him about the girls who like him on a Friday. She would see his excitement and it would trigger her and she would rage and attack. The feelings become punitive.

He wanted to be a father since the age of 10. Later in life he became a foster father to whomever would allow him to foster. He still is a mentor. Foster care trains you and tells you what the rules are. Time outs, day care and foster care parent. He watched others to learn how to love and be affectionate. At parks, at the mall. He wanted to do what the families at the park did. He would go to Irving Mall. He would sit and watch young families with small children and they would nurture them. He wanted to do that.

He graduated from TX Tech and went to Arlington, TX and majored in Child Welfare and Gang Intervention tion in Ft. Worth.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Progressing

Plan

Learn coping techniques to reduce PTSD and prepare to handle future stressful situations (thought stopping, thought switching, creative visualization, progressive muscle relaxation, deep breathing, etc.); this is sometimes called “stress inoculation training”

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Susan Colburn, LCSW, Licensed Clinical Social Worker, License 29704, signed this note and declared this information to be accurate and complete on 7/25/2024 at 2:29 ᴘᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Not Assessed
Dress:	Not Assessed
Motor Activity:	Not Assessed
Interview Behavior:	Appropriate
Speech:	Verbose
Mood:	Dysphoric
Affect:	Congruent
Insight:	Excellent
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Subjective Report and Symptom Description

Happy is experiencing hearing screams in his head that are wearing him out. It sounds like a woman. This is how a flashbacks start for him. Imagery will push through eventually. Sometimes the screaming, imagery, and flashbacks start all at once. Smells can be hay, blood, sweat. Sometimes he has an smells before the body shows up. He gets nauseous if its a bad smell. If it's the countryside he feels good. On Sunday he had a flashback for 6 hours. It would start and stop. That's the one where they're hunting and hitting people in the face. A fa and dau were loading hay into a barn. They hiked to an old cabin after they fell into a ravine. They'd gotten all dirty. There was a fa and dau. His fa killed the man. The girl ran away and hid. It made his fa mad and he chased her and killed her.He stomped at the girl's head until it was crushed and her brains came out. It would flash. He would record. It would stop for 15-20 minutes and it would start back up again. His body hurt and he was rigid. It was absolutely awful. He stayed with it so he wouldn't bother him during the week. Sometimes if he changes his location it will briefly go away but it always comes back. Sometimes it knocks him in the head.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Progressing

Plan

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Susan Colburn, LCSW, Licensed Clinical Social Worker, License 29704, signed this note and declared this information to be accurate and complete on 7/25/2024 at 3:10 ᴘᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Not Assessed
Dress:	Not Assessed
Motor Activity:	Not Assessed
Interview Behavior:	Appropriate
Speech:	Verbose
Mood:	Dysphoric
Affect:	Congruent
Insight:	Excellent
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Subjective Report and Symptom Description

The connection he made on the 29th helped him to let go of tramatic situations. When he gets a flashback there is something that holds back. Until he is able to completely recall the events in the flashback he cannot get let go. Sometimes his flashbacks come later.

Releasing the last flashback released the screaming woman. He's found he can't sleep or eat or he will feel flu like SX. When he gets the image out it goes away. It's a huge endorphin rush. Today nothing of a flashback came up. There's always something that comes up. Tic tic tic boom. This last flashback took about 4 hours to work out. He's much faster than in '97. His brain is stronger dealing with subconscious data. He remembers walking into the Piggley Wiggley people would leave their carts and leave the store. They would move the carts out of the lane to get to the cash register and whomever checked them out would not look at them. His grandfa and grandmo never talked about their past. He never knew his grandmo had a sister until a cousin told him and that they didn't talk. Sometimes the Sheriff and the Police came to his grandfa's house. He refused to answer the questions. They couldn't match bullets or have DNA. It was the same at Irving, TX, and his fa and mo refused to talk. They barged into the house and searched it for whomever disappeared. They would search the garage but never found any of the bodies. In Pineville, LA. There were two little girls into the garage. Cops would sit outside the house and wait for Max to come out. One time his fa left Happy in the car and bolted into the house. Everything he is sharing is a different flashback. They lived in a Cul de Sac and the women walked across the cul de sac and were screaming at Robert. The neighbors would come over and tell Robert they knew he did it and to move away. Happy was terrified. He was on the sidewalk. He didn't know why they were screaming. His fa sprayed them with the water hose. He didn't understand why all the adults were so made and it frightened him. His parents would leave him and cars or in the house alone. Sometimes they would leave him in the car in the woods. He was afraid he was being abandoned. He used to have a phobia of the woods but now he finds the woods peaceful. He is very afraid of having his head under water. He swims very well and his head never goes under the water unless he wants it to. He had been almost drowned by his parents as a child and watched his parents drown others. He is also afraid of boiling water. His mo always threatened to throw the boiling water on him. He saw a kid in school who had been burned by a Crockpot falling on him and how all the layers of skin burned. His mother would flick hot water and his father would flick hot grease on him. He only got nurturing from his Nana and Mammy. If anyone else was kind to him they would run them off. He thinks his good personality and the amnesia helped a lot. When he is able to talk about his trauma and bring it to the conscious state he feels so happy. He works with children that have all been traumatized. It's all structured nurturing and a lot of kind words. He uses puppets. He's trying to get them to trust him enough to allow him to hold them. They were in a pasture and moved cows around a lot. The family, share croppers, That father was talking about his own personal. Rob was being scolded about not burying the daughter deep enough. Happy was always afraid of his parents mood changes or them leaving him place. They didn't kill him because because his paternal grandmo.They did give him to his Mammy and Nana. They found a family to adopt him but as soon as his mo found out and took him out. His mo got a job as a school teacher but they didn't know where he was. If his mo was told she was a bad mo she would get his dad and they would get the person. He went to school and sometimes he had so many beat marks and such a swollen face they wouldn't let him attend school without a doctor's note. CPS showed up a couple of times. One worker told him he didn't have to go home. His mo was a teacher and would find out and they would hide him and sometimes move.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Progressing

Plan

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Susan Colburn, LCSW, Licensed Clinical Social Worker, License 29704, signed this note and declared this information to be accurate and complete on 8/1/2024 at 4:00 ᴘᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Not Assessed
Dress:	Not Assessed
Motor Activity:	Not Assessed
Interview Behavior:	Appropriate
Speech:	Verbose
Mood:	Dysphoric
Affect:	Not Assessed
Insight:	Excellent
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Severely Impaired

Risk Assessment

Suicidal ideation (Low Risk)

Intent to Act:	No
Plan to Act:	No
Means to Act:	No
Risk Factors:	Patient reports frequent thoughts when he has flashbacks
Protective Factors:	Sufficient problem-solving skills
Additional Details:	Patient reports he has frequent thoughts of suicidal ideation when he gets flashbacks of his childhood

Medications

Anxiety meds, panic pill - doesn't help, insomnia pill - more affective than the panic pill.

Subjective Report and Symptom Description

Patient reports recovered repressed memories of his childhood. Supposedly memories recovered in 1999. The memories involved his parents killing over 100 people, burning them, burying them, and other means of disposal.. he states he has flashbacks every few weeks.

And he talks about the flashbacks and then they are gone forever. This patient was transferred by another therapist.

The depression exhausts him. He will sleep for two or three days at a time. The anxiety and depression go away and he fees really good. He would be put into therapy by the school system. Sometimes there was a cop present. His mo was a teacher. Her friends would tell her parents and they would move. After that he would get severely beaten. He didn't know what happened. He was thrown in the back of the car and driven a long way.

Objective Content

Therapist going over the patient's history and his past sessions with his prior therapist. Talked about his memories and the content of same. States that he keeps the journal and has documented all of these flashbacks and has gone two three different police departments to report his memories and they tell him they are too busy to work any of these unsolved murder cases. He reports a history of being a foster parent to up to 15 young girls after the time when he started recovering his memories. He discussed his ability to get rid of the flashbacks and basically make them go away. When he speaks of these flashbacks he is very matter -of -fact, he does not endorse many symptoms of PTSD.

Interventions Used

The following interventions were used: Interactive Feedback, Cognitive Reframing, Cognitive Refocusing, Exploration of Emotions, Cognitive Challenging, Exploration of Coping Patterns, Supportive Reflection, and Psycho-Education.

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Maintained

Assessment / Additional Notes

Patient has either a history of trauma that is of the magnitude that would not be appropriate for telemedicine. If his trauma is not substantiated the patient may be suffering from a psychotic disorder. This therapist believes in either situation the patient should be seen face to face with a seasoned therapist.

IIt should be noted here that most of the patients story does not make sense, clinically or factual. He reports many contradictions, stating that he was able to live a normal life until the memories. Clinically this is not sound. He also reports that he was a foster parent for up to 15 girls in his care and that they would simply run away from home and live with him.

He reports that he began having the memories in 1999. He also reports that in 1999 this is when he began to be a foster parent for several girls in his home. Therapist vehemently questions this possibility.

It is also not probable that if this man went to the police with information about multiple murders and where the bodies were buried that they would ignore him.

This is not the course of action of police department would take

BBasically self-reported history is highly questionable and probably not true

Plan

Referred back to administrative staff for disposition

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Kathleen Pratt, LCSW, Licensed Clinical Social Worker, License 35858, signed this note and declared this information to be accurate and complete on 8/22/2024 at 7:45 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Score on GAD-7 (18) severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Anxious
Affect:	Congruent
Insight:	Excellent
Judgment/Impulse Control:	Good
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Anxiety meds, panic pill - doesn't help, insomnia pill - more affective than the panic pill.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with an anxious mood and congruent affect. Client reported on events and feelings since their last session, which included that he was feeling a little “overwhelmed” due to some recent health problems he has been dealing with. He shared that he had been transferred to the current therapist because he had “scared off” the last two therapists. Despite this, he expressed hopefulness about making reasonable progress under current care. The client continues to experience “flashbacks” of his traumatic childhood events, which contribute to heightened levels of anxiety. He is committed to reaching his treatment goals and is medication compliant without any adverse side effects. Therapist used interventions listed below with the client being responsive to them. No progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. The client's affect appeared congruent with his reported feelings of being overwhelmed. His mood seemed anxious, as evidenced by his detailed accounts of flashbacks and health concerns. Physically, he appeared well-groomed and showed no signs of acute distress during the video session. His speech was coherent and at a normal rate and volume, though it occasionally became more rapid when discussing particularly distressing topics. He was cooperative throughout the session, engaging actively in the therapeutic process. The client completed a Generalized Anxiety Disorder 7-item (GAD-7) scale and scored in the severe range with a score of 18.

Interventions Used

The following interventions were used: CBT, Motivational Interviewing, SFBT, and therapy worksheets., Cognitive Reframing, Structured Problem Solving, Cognitive Refocusing, Cognitive Challenging, Exploration of Coping Patterns, Interpersonal Resolutions, and Psycho-Education.

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: No Progress

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety remains elevated and continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client continues to experience symptoms consistent with his primary diagnosis of chronic post-traumatic stress disorder (F43.12) and secondary diagnosis of generalized anxiety disorder (F41.1). His severe score on the GAD-7 indicates significant anxiety that impacts his daily functioning. The flashbacks of traumatic childhood events appear to exacerbate his anxiety levels, contributing to his sense of being overwhelmed. Despite these challenges, he remains hopeful and committed to his treatment plan. There were no new medical problems reported, and he is compliant with his medication regimen, which he reported is not causing any adverse side effects.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The treatment plan will continue to utilize cognitive-behavioral therapy (CBT), solution-focused brief therapy (SFBT), and motivational interviewing (MI) to address the client's PTSD and anxiety symptoms. The focus will be on developing coping strategies to manage flashbacks and reduce anxiety levels. The client will also be encouraged to engage in grounding techniques and mindfulness exercises between sessions to help manage overwhelming feelings. The client will continue to monitor his medication compliance and report any side effects. Follow-up sessions will be scheduled weekly to maintain momentum and provide consistent support. Progress towards treatment goals will be reviewed regularly to ensure the client is moving towards his desired outcomes. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 9/11/2024 at 4:56 ᴘᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Score on GAD-7 (18) severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Euthymic
Affect:	Congruent
Insight:	Excellent
Judgment/Impulse Control:	Good
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a euthymic mood and congruent affect. Client reported on events and feelings since their last session, which included that he was reflecting on his weekend and shared his positive experience visiting with three of his foster kids. He expressed excitement and happiness about maintaining their continued support, which he finds very meaningful. Despite this positive interaction, he continues to experience vivid flashbacks related to his traumatic childhood events. These flashbacks remain distressing to him. He mentioned that journaling has been particularly helpful in mitigating some of his heightened symptoms and allows him to reflect on his experiences. He continues to use his coping skills diligently and remains committed to reaching his treatment goals. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. Throughout the session, the client's mood appeared generally positive when discussing his weekend visit, though he became visibly distressed when recounting his traumatic flashbacks. His affect was congruent with his mood, showing appropriate emotional responses to different topics discussed. He demonstrated clear and coherent speech, and his behavior was cooperative and engaged. Physically, there were no new medical problems reported, and he appeared well-groomed and attentive. He confirmed being medication compliant and reported not experiencing any adverse side-effects from his medication regimen.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Progressing

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety is starting to lessen but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is making notable progress in his treatment, as indicated by his ability to reflect on positive experiences and maintain supportive relationships with his foster children. However, the persistent vivid flashbacks associated with his childhood trauma continue to be a significant source of distress. His engagement in therapeutic modalities such as CBT (Cognitive Behavioral Therapy), SFBT (Solution-Focused Brief Therapy), and MI (Motivational Interviewing) appears to be effective. His commitment to utilizing coping strategies, particularly journaling, has been beneficial in managing his symptoms. Despite the ongoing challenges, his dedication to his treatment goals remains strong, signaling a positive outlook for continued progress.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals.

Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The client will continue to engage in weekly video sessions focusing on CBT, SFBT, and MI to address his PTSD and generalized anxiety disorder. He will maintain his journaling practice as a primary coping mechanism and will be encouraged to explore additional coping strategies that may provide further relief. The therapist will monitor his flashbacks closely and work on specific interventions to reduce their frequency and intensity. Medication compliance will be regularly assessed to ensure its efficacy and to monitor for any potential side-effects. The client will also be encouraged to maintain his supportive relationships, as these appear to be a significant positive influence on his mental health. Follow-up sessions will continue to track his progress towards his treatment goals. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Every 2 Weeks

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 9/25/2024 at 4:53 ᴘᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Score on GAD-7 (18) severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Neutral
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a neutral mood and congruent affect. Client reported on events and feelings since their last session, which included that he was experiencing ongoing stressors related to his chronic post-traumatic stress disorder, particularly his "flashbacks" which he attributes to a "dysfunctional childhood." He expressed that while he is making an effort to maintain a positive and hopeful outlook, there are times when "the memories seem to be very vivid, and I feel like I’m reliving the experiences again." Despite these challenges, he is actively utilizing coping skills and techniques acquired through psychoeducation. The client highlighted journaling and spending quality time with his foster children as effective strategies in managing his symptoms. He indicated that these activities help in keeping his symptoms to a minimum and expressed a strong determination to continue working towards his treatment goals. He reported no new medical issues and confirmed compliance with his medication regimen, noting no adverse side effects. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. During the video session, the client appeared appropriately dressed and engaged in the therapeutic process. His speech was coherent and reflected a consistent effort to articulate his experiences and strategies for coping with his symptoms. His affect appeared congruent with the discussion, displaying moments of reflection and insight when discussing the impact of his childhood on his current mental health. He demonstrated an understanding of the therapeutic techniques being applied, namely Cognitive Behavioral Therapy (CBT), Solution-Focused Brief Therapy (SFBT), and Motivational Interviewing (MI), and expressed ongoing commitment to applying these strategies. His behavior throughout the session was cooperative and attentive, indicating a readiness to continue with the therapeutic process. He did not exhibit any physical distress or agitation during the session.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Variable

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to improve but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is progressing in his treatment for chronic post-traumatic stress disorder and generalized anxiety disorder. He continues to experience vivid memories and flashbacks related to past trauma, which can occasionally challenge his attempts to stay positive. However, he is effectively employing coping mechanisms and therapeutic techniques, demonstrating resilience and a proactive approach to managing his symptoms. His commitment to treatment goals and regular use of psychoeducation tools suggests a positive trajectory in his mental health journey. The absence of new medical problems and adherence to his medication regimen further support his stability and capacity to engage in therapeutic work. Overall, the client is making steady progress, maintaining a balance between managing symptoms and fostering a hopeful outlook.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The treatment plan will continue to focus on reinforcing the client's use of CBT, SFBT, and MI to address PTSD and generalized anxiety symptoms. Additional psychoeducation materials will be provided to enhance his understanding and application of coping strategies. Continued encouragement of journaling and engaging in meaningful activities with his foster children will be prioritized to support his emotional regulation and symptom management. Regular assessment of his medication compliance and any potential side effects will be maintained to ensure his physical well-being is not compromised. Future sessions will aim to further strengthen his resilience and explore any emerging themes related to his traumatic memories, providing a safe space for processing and growth. Follow-up sessions will be scheduled to monitor his progress and adjust the therapeutic approach as necessary to support his continued advancement towards his treatment goals. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Every 2 Weeks

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 10/9/2024 at 4:53 ᴘᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Score on GAD-7 (18) severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Euthymic
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a euthymic mood and congruent affect. Client reported on events and feelings since their last session, which included that he continues to experience some anxiety and distress but has been able to manage these feelings effectively. He expressed a sense of accomplishment in observing positive results from his efforts to cope with his symptoms. He articulated that being intentional about symptom management has been beneficial, particularly during challenging times. The client shared that his dedication to incorporating coping skills and techniques from his psychoeducation has strengthened his ability to handle stress. He conveyed a sense of pride in his ongoing learning about emotion regulation, self-identity, and improving interpersonal relationships. The client remains motivated and committed to achieving his treatment goals. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. During the session, the client's mood appeared stable, and his affect was congruent with the topics discussed. He demonstrated clear and coherent speech, which was goal-directed and appropriate for the context of the session. His behavior was engaged and participatory, indicating a proactive approach to his therapeutic work. The client reported no new medical issues and confirmed that he is medication compliant without experiencing any adverse side effects. There were no physical symptoms or concerns observed during the session that required attention. He seems to be effectively utilizing the skills and techniques discussed in previous sessions, particularly in managing anxiety and stress.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Improved

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to improve but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is diagnosed with chronic post-traumatic stress disorder (F43.12) and generalized anxiety disorder (F41.1). He is making progress in managing his symptoms, as evidenced by his reported success in applying coping strategies and psychoeducational techniques. His ability to intentionally manage symptoms during difficult moments indicates a growing mastery of emotion regulation skills. The use of cognitivebehavioral therapy (CBT), solution-focused brief therapy (SFBT), and motivational interviewing (MI) continues to support his therapeutic journey. The client remains committed to reaching his treatment goals, and his proactive approach suggests a positive trajectory in his mental health management. There are no current concerns about his progress or adherence to the treatment plan.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals.

Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The therapeutic plan will continue to focus on reinforcing the client’s coping strategies and enhancing his skills in emotion regulation, self-identity, and relationship building. The continuation of CBT, SFBT, and MI will be employed to further support his progress. Regular check-ins on his symptom management and coping strategies will be scheduled to ensure ongoing support and adjustment of techniques as needed. Encourage the client to maintain his medication compliance and monitor any potential side effects. Future sessions will explore deeper into areas of self-identity and relationship dynamics to facilitate further growth. The client's commitment to his treatment goals will be supported by revisiting and refining these goals as he progresses. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 10/22/2024 at 10:53 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Score on GAD-7 (18) severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Neutral
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a neutral mood and congruent affect. Client reported on events and feelings since their last session, which included that he was having a "relatively good morning," expressing optimism about the rest of his day being productive. He is currently working from home and took a break to attend the session, highlighting his commitment to integrating therapy into his daily routine. He shared that he continues to use coping skills and implement behavioral modifications, which have been beneficial overall. However, he acknowledged that he still encounters struggles occasionally, indicating an ongoing challenge in managing his symptoms. Despite these challenges, he remains engaged in utilizing the techniques learned through psychoeducation to work towards his treatment goals. He emphasized his commitment to learning coping techniques to reduce PTSD symptoms and prepare for future stressful situations. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. The client appeared engaged and focused during the video session, displaying a stable affect and a positive mood as he discussed his progress and challenges. His speech was clear and coherent, indicating an organized thought process. There were no signs of physical distress, and his behavior was cooperative and attentive throughout the session. He demonstrated insight into his condition and the effectiveness of his coping strategies, indicating a good understanding of the therapeutic process. His continued use of CBT, SFBT, and MI techniques suggests he is actively participating in his treatment plan. No new medical issues were reported, and he confirmed that he remains medication compliant without experiencing any adverse side effects.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Variable

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to lower but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is progressing in his treatment plan, as evidenced by his ability to have "relatively good" days and his active use of coping strategies to manage his PTSD and generalized anxiety disorder symptoms. His commitment to integrating therapy into his daily routine, even while working from home, indicates a strong motivation to achieve his treatment goals. Despite occasional struggles, his consistent use of psychoeducation techniques points to an improvement in his ability to handle stress. The absence of new medical problems and his adherence to medication compliance further support his positive progression. Overall, the client is showing a steady improvement in managing his symptoms and remains dedicated to his therapeutic journey.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The treatment plan will continue to focus on enhancing the client's coping skills and behavioral modifications through CBT, SFBT, and MI modalities. Regular sessions will be maintained to ensure ongoing support and guidance as he works towards his treatment goals. Psychoeducation will continue to be a significant component, providing him with tools to anticipate and manage future stressful situations effectively. Monitoring of medication compliance will persist, with attention to any potential side effects. Encouragement will be given to maintain his commitment to therapy and to recognize and celebrate small victories in his progress. Future sessions will also explore any new challenges or triggers that may arise, ensuring a comprehensive approach to his mental health care. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 10/29/2024 at 10:53 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Score on GAD-7 (18) severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Neutral
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a neutral mood and congruent affect. Client reported on events and feelings since their last session, which included that he continues to experience ongoing issues related to his anxiety and distress. He expressed that his chronic post-traumatic stress disorder continues to be heavily influenced by persistent flashbacks from his traumatic childhood. These flashbacks are primarily triggered by memories of his late parent’s "crime spree." Despite these challenges, the client noted that he is seeing tangible results from the coping skills he has been utilizing, which suggests a positive shift in managing his anxiety. He conveyed a strong sense of determination to reach his treatment goals and emphasized that he remains focused on fostering progress. The client did not report any new medical problems, and he confirmed medication compliance without experiencing any adverse side effects. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

His speech was coherent, and he engaged actively in the conversation, indicating a willingness to explore his feelings and thoughts. Physically, he appeared well-groomed and attentive, suggesting that he is maintaining his self-care routines despite the psychological challenges he faces. His behavior was cooperative and engaged, reflecting a commitment to the therapeutic process. The client’s focus on utilizing coping strategies such as cognitive-behavioral techniques and solution-focused methods illustrates his proactive approach to managing his symptoms. There were no indications of any immediate risk factors, and he continues to demonstrate insight into his condition.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Variable

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to lessen but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is showing signs of progression in his therapeutic journey as he continues to implement coping strategies effectively. His acknowledgment of the impact of childhood trauma on his current distress is a significant step in processing and managing these experiences. The continued use of cognitive-behavioral therapy (CBT), solution-focused brief therapy (SFBT), and motivational interviewing (MI) is providing him with a structured framework to address his symptoms. The client’s ability to remain medication compliant without adverse effects supports his overall treatment plan. His self-reported progress towards his goals indicates a positive trajectory, though the persistence of flashbacks suggests that ongoing support and adjustment of strategies may be necessary.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The treatment plan will continue to focus on addressing the symptoms of post-traumatic stress disorder and generalized anxiety disorder using a combination of CBT, SFBT, and MI. Emphasis will be placed on reinforcing and expanding the client's coping skills, targeting the reduction of flashbacks, and managing anxiety. Future sessions will explore deeper aspects of his childhood trauma, with the aim of processing these memories in a safe and supportive environment. The client will be encouraged to maintain his medication regimen and to report any changes or side effects promptly. Regular monitoring of his progress towards treatment goals will be conducted to ensure that he remains on track and to make any necessary adjustments to the therapeutic approach. Continued engagement in therapy will be encouraged to support his commitment to personal growth and healing. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 11/5/2024 at 10:54 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Score on GAD-7 (18) severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Neutral
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a neutral mood and congruent affect. Client reported on events and feelings since their last session, which included that he was having a “not so good” morning. He attributed this primarily to experiencing “severe flashbacks” related to his traumatic memories, which have significantly affected his mood and sleep. He reported ongoing struggles with heightened anxiety and distress, particularly when he recalls the “crimes” his family committed against others, sometimes in his presence during childhood. Despite these challenges, the client expressed a continued commitment to working towards his treatment goals. He mentioned that he is actively employing coping skills to manage symptoms associated with his anxiety and PTSD. The client did not report any new medical issues or adverse side effects from his current medication regimen. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. During the session, the client's mood appeared anxious and distressed, consistent with his verbal reports. His affect was congruent with the anxious and reflective nature of the session, often showing signs of agitation when discussing his traumatic memories. Physically, he appeared somewhat fatigued, likely due to the sleep disturbances he mentioned. His speech was coherent and appropriately paced, though it occasionally became more rapid when discussing particularly distressing memories. Behaviorally, he engaged actively in the session, demonstrating a willingness to discuss difficult topics and explore therapeutic techniques. There were no observable new medical concerns, and he did not report any side effects from his medication.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Variable

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to lessen but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client continues to exhibit symptoms of chronic PTSD and generalized anxiety disorder. His experience of “severe flashbacks” and sleep disturbances is indicative of the ongoing challenges he faces with PTSD. The anxiety and distress he feels when recalling his family's “crimes” suggest that these memories are significant triggers for his symptoms. Despite these difficulties, there is a positive indication of progress, as he remains committed to his treatment goals and is actively using coping strategies. The therapeutic modalities of CBT, SFBT, and MI have shown some favorable outcomes, which is encouraging in his overall treatment progression. Overall, the client is progressing, although he continues to face significant emotional challenges.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals.

Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The plan is to continue using a combination of CBT, SFBT, and MI to help the client manage his PTSD and anxiety symptoms effectively. Emphasis will be placed on further developing and refining coping strategies to deal with flashbacks and sleep disturbances. The client will be encouraged to continue reflecting on his traumatic memories in a controlled and therapeutic manner, aiming to reduce their emotional impact. Regular assessment of his medication regimen will be maintained to ensure no adverse side effects arise. The client will be supported in maintaining his commitment to his treatment goals, and additional resources or interventions will be considered as needed to aid his progress. A follow-up session will be scheduled to monitor his emotional state and adjust the treatment plan as necessary. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 11/12/2024 at 10:54 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Score on GAD-7 (18) severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Euthymic
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a euthymic mood and congruent affect. Client reported on events and feelings since their last session, which included that he was experiencing a slow start to his day, attributing this to a restless night filled with flashbacks of repressed childhood memories. These flashbacks are associated with the traumatic events he witnessed, involving crimes committed by his parents. Despite these challenges, he expressed that he has observed slight progress week-over-week. The client shared that he has been actively engaging in self-help strategies, such as journaling his thoughts and reflecting on them. He finds these practices beneficial in conjunction with the therapy sessions. Additionally, he mentioned feeling more in control by focusing on what he can manage and remains determined to reach his treatment goals. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. Throughout the session, the client appeared engaged and forthcoming about his experiences. His speech was clear, coherent, and reflected his ongoing efforts to manage his symptoms of PTSD and anxiety. His mood was somewhat subdued, likely due to the restless night and the emotional weight of the flashbacks, but it was noted that he could articulate his thoughts and feelings effectively. He showed a commitment to his therapeutic journey by discussing the progress he perceives, albeit slight. There were no new medical issues reported, and he confirmed adherence to his medication regimen without experiencing any adverse side effects. His behavior during the session was consistent with previous interactions, displaying a willingness to work on his challenges.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Improved

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to improve but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client continues to exhibit symptoms of chronic PTSD and generalized anxiety disorder, as evidenced by the flashbacks and restless nights. However, there is a noticeable trend of slow but steady progress. His engagement in self-reflective practices, such as journaling, indicates a proactive approach to his mental health. The use of cognitive-behavioral therapy (CBT), motivational interviewing (MI), and solution-focused brief therapy (SFBT) has been effective, with the client reporting favorable outcomes from these modalities. His focus on controlling what he can and his dedication to achieving his treatment goals are positive indicators of his ongoing progression. Overall, the client's commitment to therapy and self-help strategies is contributing to his gradual improvement.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals.

Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The therapeutic plan will continue to focus on the current modalities: CBT, MI, and SFBT, as they have been beneficial for the client. Encouraging him to maintain his journaling and self-reflection practices will be essential, as these have supported his progress. The client will be advised to monitor his sleep patterns and identify any potential triggers for his restless nights. Continual emphasis will be placed on building coping strategies to manage flashbacks and anxiety symptoms. Regular follow-ups on medication adherence and any potential side effects will be maintained. The client will be encouraged to set small, achievable goals to sustain his momentum toward reaching his overall treatment objectives. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 11/19/2024 at 10:54 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Score on GAD-7 (18) severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Euthymic
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a euthymic mood and congruent affect. Client reported on events and feelings since their last session, which included that he was in the process of starting his day and was hopeful about completing some errands he had been procrastinating on. He shared a sense of optimism about having a productive day and week ahead. The client reported observing positive outcomes from his efforts both in and outside of therapy. He stated that he feels he is doing better week-over-week as he continues to process his traumatic memories. He emphasized his commitment to working towards his treatment goals and noted that he is seeing progress in this area, attributing his improvements to his focus and diligence. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. The client's affect appeared consistent with his reported mood, which was optimistic and hopeful. Throughout the session, he exhibited a positive and engaged demeanor. His speech was clear, coherent, and goal-directed, reflecting his motivation to continue progressing in therapy. There were no signs of distress or agitation, and his behavior was appropriate and cooperative during the session. He reported no new medical problems and confirmed adherence to his medication regimen without experiencing any adverse side effects. His physical appearance was well-kept and appropriate for the setting, suggesting good self-care practices.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Improved

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to lessen but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is diagnosed with chronic post-traumatic stress disorder and generalized anxiety disorder. He appears to be making significant progress in therapy, as evidenced by his self-reported improvements and observable changes in his behavior and outlook. The use of cognitive-behavioral therapy (CBT), motivational interviewing (MI), and solution-focused brief therapy (SFBT) continues to yield favorable results. The client's commitment to processing his traumatic memories and working towards his treatment goals is evident and contributing to his overall progression. His ability to articulate his experiences and maintain medication adherence without side effects further supports the positive trajectory of his treatment.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The therapeutic plan will continue to focus on utilizing CBT, MI, and SFBT to support the client's treatment goals and help him process traumatic memories. Encouragement will be provided for the client to maintain his current level of diligence and focus, as these have been instrumental in his progress. The client will be encouraged to monitor his daily activities and self-care routines to ensure continued productivity and emotional well-being. Regular check-ins on his medication adherence and any potential side effects will remain a priority. The next session will aim to explore any new challenges he may face and reinforce strategies to manage his anxiety and PTSD symptoms effectively. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 11/26/2024 at 10:54 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Score on GAD-7 (18) severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Euthymic
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a euthymic mood and congruent affect. Client reported on events and feelings since their last session, which included that he was starting his day off on a positive note and felt that, overall, he was doing better compared to the previous week. He noted that his sleep quality had improved, which was accompanied by a reduction in the frequency of flashbacks. The client shared that his small support system, mainly consisting of his foster children, continues to be a source of strength for him. He is actively trying to maintain a positive and hopeful outlook on his circumstances. However, he acknowledged a tendency to catastrophize, which sometimes negatively impacts his mood. Despite these challenges, he is dedicated to leveraging his coping skills and the psychoeducation he has received to mitigate episodes of heightened anxiety and distress. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client continues to practice cognitive-behavioral techniques and motivational interviewing strategies to address his symptoms. Additionally, he utilizes solution-focused brief therapy with mostly favorable outcomes, indicating that these therapeutic modalities are effective for him.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Improved

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to reduce but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is showing signs of positive progression in managing his chronic post-traumatic stress disorder and generalized anxiety disorder. His improved sleep and reduced flashbacks suggest a stabilization in his condition. The reliance on his support system and use of coping mechanisms reflects a proactive approach in dealing with his challenges. His awareness of the tendency to catastrophize and its impact on his mood indicates a growing insight into his mental health. The client's adherence to treatment and the effectiveness of the therapeutic modalities being used are contributing to his overall improvement. Continued focus on these areas will be beneficial in sustaining his progress.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The therapeutic plan will continue to focus on reinforcing the client's use of coping skills and psychoeducation to manage anxiety and distress. Cognitivebehavioral therapy, motivational interviewing, and solution-focused brief therapy will remain the core modalities, given their effectiveness in the client's treatment thus far. Encouraging the client to further strengthen his support system, especially involving his foster children, will be prioritized to enhance his emotional resilience. Ongoing monitoring of medication adherence and side effects will continue to ensure no adverse impacts. Future sessions will aim to address the client's tendency to catastrophize, with the goal of developing healthier cognitive patterns. Regular follow-ups will assess progress and make necessary adjustments to the treatment plan. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 12/10/2024 at 10:51 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Score on GAD-7 (18) severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Euthymic
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a euthymic mood and congruent affect. Client reported on events and feelings since their last session, which included that he had been experiencing a relatively good day and week. He reflected positively on his recent Christmas holiday, which he spent mostly with his family. He felt that the holiday had been a success overall and was pleased with the quality time he was able to spend with some of his foster children, an opportunity that he does not often get. While he acknowledged experiencing some intermittent distress and anxiety, he noted that these feelings were less intense compared to previous sessions. He expressed optimism about the positive changes he continues to observe in himself. The client remains focused on achieving his treatment goals and frequently utilizes coping skills to manage heightened symptoms. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. During the session, the client appeared well-groomed and engaged. His speech was coherent and goal-directed, reflecting a clear and organized thought process. He demonstrated a stable mood, and his affect was congruent with the content of his speech, suggesting a balanced emotional state. There were no signs of psychomotor agitation or retardation observed throughout the session. The client continues to adhere to his medication regimen without reporting any adverse side effects. He remains committed to his therapeutic process, consistently engaging in the session and showing insight into his progress and areas of improvement.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Improved

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to reduce but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is showing signs of progression in managing his chronic post-traumatic stress disorder and generalized anxiety disorder. His ability to reflect positively on his experiences, such as the recent holiday with his family, indicates improved mood regulation and coping strategies. The reduction in the intensity of distress and anxiety symptoms is a positive indicator of the effectiveness of the therapeutic interventions being employed. The client's continued focus on treatment goals and frequent utilization of coping skills suggests a proactive approach to his mental health. The therapeutic modalities of Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI), and Solution-Focused Brief Therapy (SFBT) are producing favorable results. Overall, the client is demonstrating resilience and adaptability in his journey towards improved mental health.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The plan is to continue with the current therapeutic approach, maintaining the use of CBT, MI, and SFBT, as the client reports favorable results from these modalities. Encourage the client to maintain medication adherence and monitor for any potential side effects. It is important to continue reinforcing his use of coping skills to manage symptoms of anxiety and distress. Future sessions will focus on supporting the client in achieving his treatment goals and addressing any barriers that may arise. Regular check-ins on the client’s emotional state and experiences will be essential to ensure continued progress. The therapeutic alliance remains strong, and ongoing engagement in sessions will support the client's path toward sustained mental health and well-being. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 12/27/2024 at 10:52 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Score on GAD-7 (18) severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Euthymic
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a euthymic mood and congruent affect. Client reported on events and feelings since their last session, which included that he was having a good morning and felt positive about his week overall. He expressed a sense of progression in a mostly favorable manner and did not report any distress or heightened levels of symptomology. He shared that he sees progress in some areas of functioning, acknowledging that he still struggles in others. Despite these challenges, he remains committed to staying positive and focused on the aspects of his life within his control. He continues to utilize coping skills and psychoeducation strategies, which he believes are yielding tangible results. The client did not mention any new medical issues and confirmed medication compliance without any adverse side effects. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. During the video session, the client appeared engaged and attentive, maintaining consistent eye contact and displaying appropriate affect. His speech was clear and coherent, reflecting his positive mood and willingness to discuss his progress and challenges openly. The client's behavior was calm and composed, demonstrating an understanding and application of the therapeutic techniques discussed in previous sessions. He appeared physically well, with no visible signs of distress or discomfort. The client seemed motivated to continue working on his goals, as evidenced by his proactive approach to utilizing coping mechanisms and psychoeducation.

Overall, the client's demeanor and presentation were consistent with his self-reported positive outlook.

Interventions Used

Treatment Plan Progress

Objectives

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Improved

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to lessen but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client continues to show signs of progression in managing his chronic post-traumatic stress disorder and generalized anxiety disorder. His ability to identify areas of improvement and acknowledge ongoing challenges indicates a healthy level of self-awareness and insight. The application of cognitivebehavioral therapy (CBT), solution-focused brief therapy (SFBT), and motivational interviewing (MI) appears to be effective, contributing to the client's reported favorable outcomes. His compliance with medication and absence of adverse side effects further supports his overall progress. Despite some ongoing struggles, the client remains focused on maintaining control over his circumstances, demonstrating resilience and perseverance. His positive self-report and engagement in the therapeutic process suggest continued improvement in his mental health.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The plan is to continue with the current therapeutic approach, utilizing CBT, SFBT, and MI, as these modalities have proven effective for the client. Encourage the client to maintain his proactive use of coping skills and psychoeducation strategies, reinforcing his efforts and acknowledging his progress. Monitor any changes in his mental health status and be vigilant for potential challenges that may arise. Continue to assess medication compliance and side effects, ensuring that the client remains informed and comfortable with his treatment plan. Schedule regular follow-up sessions to provide ongoing support and address any emerging issues. Reinforce the client's strengths and resilience, encouraging him to persist in his efforts to manage his symptoms and improve his overall well-being. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 12/31/2024 at 10:54 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Score on GAD-7 (18) severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Neutral
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a neutral mood and congruent affect. Client reported on events and feelings since their last session, which included that he continues to experience fluctuations in the intensity of his symptoms. Despite these ups and downs, he acknowledged having more good days than bad ones, indicating a sense of progression in his overall mental health. He expressed feeling like he’s making progress and observing positive changes in his daily functioning. Notably, he shared that he is experiencing fewer problems with flashbacks from his traumatic memories. This reduction in flashbacks has allowed him to achieve better rest and improve his sleep quality, leading to enhanced relationships with those around him. He reiterated that his treatment goals remain a priority and emphasized the value of his coping skills, and the psychoeducation provided during therapy. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. Throughout the session, the client appeared engaged and communicative, displaying a willingness to discuss his current experiences and progress. His speech was coherent, and he articulated his thoughts clearly, reflecting an organized thought process. Behaviorally, he maintained focus and actively participated in the therapeutic process, demonstrating an understanding of his treatment modalities. There were no reports of new medical issues, and he confirmed consistent medication compliance without experiencing any adverse side effects. His affect seemed congruent with the content of the discussion, showing a range of emotions appropriate to the topics addressed. Overall, he continues to respond well to the therapeutic modalities of CBT, MI, and SFBT, indicating their effectiveness in managing his symptoms.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Variable

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to lower but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is making notable progress in managing his symptoms associated with PTSD and generalized anxiety disorder. The reduction in flashbacks and improvement in sleep quality are significant indicators of therapeutic benefit and positive change. His acknowledgment of more good days than bad ones suggest a stable trend toward improvement, which aligns with his self-reported experiences of enhanced daily functioning and better relationships. The client's commitment to his treatment goals and the utilization of coping strategies and psychoeducation are crucial factors contributing to his progression. Continual engagement with CBT, MI, and SFBT appears beneficial, as evidenced by his ongoing responsiveness to these therapeutic approaches. The absence of new medical concerns and adherence to medication further support the stability of his current treatment plan.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The plan is to continue with the established therapeutic modalities, including CBT, MI, and SFBT, as they have proven effective for the client. Emphasis will be placed on reinforcing his coping skills and psychoeducation to further empower him in managing his symptoms. Regular monitoring of his progress will be conducted, with attention to any fluctuations in symptom intensity or other changes in his mental or physical health. The client will be encouraged to maintain open communication about his experiences and any challenges he may encounter. Medication compliance will continue to be assessed to ensure its ongoing effectiveness and absence of side effects. The therapeutic services remain medically necessary to support his continued progress and overall well-being. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 1/7/2025 at 10:51 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Score on GAD-7 (18) severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Euthymic
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a euthymic mood and congruent affect. Client reported on events and feelings since their last session, which included that he was feeling generally positive about his day and noted that his week was moving in an upward trajectory, suggesting a sense of optimism about his current situation. He articulated that he continues to observe improvements in various areas of functioning, which has been encouraging for him. Nevertheless, the client acknowledged that he still encounters episodes of distress and anxiety, primarily linked to sleep disturbances and flashbacks. These episodes are residual effects stemming from his dysfunctional upbringing and traumatic memories. Despite these challenges, he expressed a firm commitment to his treatment goals. He emphasized the importance and effectiveness of the psychoeducation provided and the coping skills he has been utilizing, which have contributed positively to his experiences outside of therapy. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. During the session, the client appeared engaged and motivated, actively participating in the discussion about his progress and ongoing challenges. His speech was clear, coherent, and appropriate in both tone and pace, reflecting a stable mood. There were no observable physical signs of distress during the session, and his affect was congruent with the topics discussed. The client reported no new medical issues and confirmed compliance with his prescribed medication regimen. His behavior during the session was cooperative and focused, providing detailed accounts of his experiences and responses to the therapeutic interventions. The therapeutic modalities of Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI), and Solution-Focused Brief Therapy (SFBT) continue to be effectively integrated into his treatment plan.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Improved

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to improve but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is demonstrating positive progression in managing the symptoms associated with his chronic post-traumatic stress disorder and generalized anxiety disorder. His ability to recognize and articulate the improvements in his functioning indicates an enhanced self-awareness and adaptive coping mechanisms. While he continues to experience distress related to sleep and flashbacks, his commitment to treatment and the utilization of coping strategies are aiding in mitigating the impact of these symptoms. The client's adherence to psychoeducation and consistent use of therapeutic skills outside of sessions suggest a strong therapeutic alliance and engagement in the treatment process. The absence of new medical concerns and continued medication compliance further supports a stable trajectory in his mental health management. Overall, services remain medically necessary to support his continued progress and address residual symptoms.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The treatment plan will continue to focus on reinforcing the client's coping skills and psychoeducation to manage symptoms of PTSD and anxiety effectively. Ongoing use of CBT, MI, and SFBT will be emphasized to support the client in addressing and processing traumatic memories while reducing sleep disturbances and anxiety. We will explore additional strategies to enhance his sleep hygiene and minimize the impact of flashbacks on his daily functioning. Regular monitoring of the client's medication adherence will be maintained to ensure therapeutic efficacy. Future sessions will aim to further bolster his resilience and self-efficacy, with an emphasis on maintaining the positive momentum he has reported. The client will be encouraged to continue applying learned skills outside of therapy to reinforce progress and support sustained improvement in his mental health. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 1/14/2025 at 10:51 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Score on GAD-7 (18) severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Euthymic
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a euthymic mood and congruent affect. Client reported on events and feelings since their last session, which included that he was feeling "generally okay" and acknowledged some progress in his overall functioning. While he continues to face challenges with sleep, he noted a significant decrease in the frequency and intensity of traumatic memories and flashbacks. He spoke positively about his involvement in activities that provide comfort and balance, particularly highlighting the time spent with his foster children as a source of meaningful connection. The client expressed a strong commitment to his treatment goals, emphasizing the importance of maintaining his progress. He shared that he has been effectively using the coping skills discussed in therapy, which have helped him navigate daily stressors more efficiently. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. Throughout the session, the client's mood appeared stable, and his affect was congruent with the topics discussed, reflecting a range of emotions appropriate to the conversation. He demonstrated clear and coherent speech, engaging actively in the dialogue with thoughtful contributions. Physically, he looked well-groomed and appeared to be in good health, as there were no observable signs of distress or discomfort. His behavior was cooperative and engaged, as he was attentive and responsive during the session. The client has shown a consistent pattern of utilizing coping mechanisms and integrating psychoeducation into his daily life, which he reports has yielded mostly positive outcomes. He did not disclose any new medical issues and remains compliant with his prescribed medication, experiencing no adverse side effects.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Improved

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to lessen but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is progressing in his treatment, as evidenced by his self-reported decrease in traumatic memories and flashbacks, along with his ability to engage in meaningful activities. His ongoing commitment to treatment goals and effective use of coping strategies are indicative of his dedication to improving his mental health. The decrease in symptoms related to his primary diagnosis of chronic PTSD suggests that the therapeutic interventions employed, such as Cognitive Behavioral Therapy (CBT), Solution-Focused Brief Therapy (SFBT), and Motivational Interviewing (MI), are benefiting him. His secondary diagnosis of Generalized Anxiety Disorder also appears to be managed well, as he did not report any significant increases in anxiety symptoms. The client's engagement in fostering relationships with his foster children further supports his progress in building and maintaining social connections, which are crucial for his overall well-being.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The treatment plan will continue to focus on reinforcing the client's use of effective coping strategies and maintaining the progress achieved thus far. The therapeutic approach will remain centered around CBT, SFBT, and MI to address both the client's PTSD and generalized anxiety symptoms. Continued psychoeducation will be provided to enhance the client's understanding of his conditions and to support his ability to manage symptoms independently. Emphasis will be placed on improving sleep hygiene and exploring additional strategies to address sleep disturbances. The client will be encouraged to sustain his engagement in meaningful activities and relationships, particularly with his foster children, as these have been beneficial for his mental health. Regular monitoring of his medication compliance and side effects will continue to ensure there are no adverse reactions, and the necessity of services will be reassessed periodically to align with the client's ongoing needs and progress. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 1/21/2025 at 10:51 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Score on GAD-7 (18) severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Neutral
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a neutral mood and congruent affect. Client reported on events and feelings since their last session, which included that he had been having flashbacks both last night and earlier in the day, which were distressing and contributed to elevated mood and anxiety levels. Although he had a few days without flashbacks, he described the past 24 hours as particularly challenging, largely due to poor sleep. The client shared that spending time with his foster children has been a positive aspect of his life, as it lifts his spirits and provides motivation. He expressed that he remains committed to utilizing coping skills, which have yielded mostly favorable results. He voiced motivation towards achieving his treatment goals, noticing some progress in his journey. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. During the session, the client appeared engaged and articulate, with coherent speech that was goal-directed. His affect was appropriate to the content discussed, although it fluctuated when recounting recent distressing events, indicating underlying anxiety. His mood was described as anxious, consistent with his report of recent flashbacks. Physically, he presented with no observable signs of distress or fatigue, despite reporting poor sleep. His behavior throughout the session was cooperative, demonstrating active participation and a willingness to explore both challenges and coping strategies. No new medical issues were reported, and he confirmed compliance with his medication regimen without experiencing any adverse side effects.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Variable

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to improve but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client continues to experience symptoms consistent with his diagnosis of chronic post-traumatic stress disorder, including flashbacks that negatively impact his mood and anxiety. The recent increase in flashbacks suggests a temporary regression, albeit against a backdrop of overall progress. His generalized anxiety disorder remains a secondary concern, exacerbated by poor sleep and the distressing nature of his flashbacks. Despite these challenges, the client has demonstrated resilience by effectively employing coping mechanisms and drawing support from positive interactions with his foster children. His motivation to achieve his treatment goals is evident, and he acknowledges the progress he has made, which is encouraging for future sessions. The therapeutic interventions, including CBT, SFBT, MI, and psychoeducation, appear to be beneficial, as he remains engaged and committed to therapy.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The plan is to continue with weekly video sessions to maintain the therapeutic alliance and monitor the client's symptoms and progress. The use of cognitive-behavioral techniques will be reinforced to help him manage and reduce the occurrence of flashbacks and anxiety. Solutionfocused brief therapy will focus on building resilience and identifying short-term goals, particularly around improving sleep hygiene. Motivational interviewing will continue to support his commitment and motivation towards his treatment objectives. Psychoeducation will be employed to further enhance his understanding of PTSD and anxiety and their impact on his well-being. The client will be encouraged to maintain his medication regimen, and any changes in symptoms or side effects will be closely monitored. Additionally, the client will be encouraged to continue engaging in activities that provide joy and motivation, such as spending time with his foster children, to bolster his emotional well-being. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 2/4/2025 at 10:52 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Score on GAD-7 (18) severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Neutral
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a neutral mood and congruent affect. Client reported on events and feelings since their last session, which included that he was experiencing a good morning and was at a local coffee shop, where he was eagerly waiting to meet with a couple of adult foster kids. The client expressed that such gatherings are uplifting, as these opportunities are not frequent. However, the client reported ongoing distress and anxiety, primarily linked to flashbacks of repressed childhood memories associated with trauma under parental care. Despite these challenges, the client noted consistent use of coping strategies and motivation toward achieving treatment goals. The client expressed satisfaction with the progress made thus far. No new medical concerns were raised, and the client indicated adherence to medication without adverse effects. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. The client presented in a stable condition during the video session. Affect and mood appeared appropriate as the client discussed both positive and distressing experiences. The speech was coherent and normal in rate and volume, indicating engagement in the therapeutic process. The client demonstrated behaviors consistent with active participation and motivation in therapy, utilizing therapeutic modalities such as CBT, SFBT, MI, and psychoeducation. There were no signs of physical distress observed, and the client maintained composure throughout the session. The client's self-reported adherence to medication suggests a commitment to managing symptoms effectively.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Variable

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to lessen but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client continues to experience symptoms consistent with chronic post-traumatic stress disorder (F43.12) and generalized anxiety disorder (F41.1). The primary struggle remains the distress triggered by flashbacks of childhood trauma. However, the client's use of coping skills and engagement in therapy reflect progress. The client’s motivation and positive response to therapeutic interventions demonstrate a trajectory toward improvement. The absence of new medical issues and the client's compliance with medication suggest that the current treatment plan is effective. Overall, the client is progressing in managing symptoms and achieving therapeutic goals.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The treatment plan will continue to focus on addressing symptoms related to PTSD and anxiety through established modalities, including cognitivebehavioral therapy, solution-focused brief therapy, motivational interviewing, and psychoeducation. The client will be encouraged to maintain the use of coping strategies and monitor the effectiveness of these techniques. Regular check-ins on medication adherence and side effects will be conducted to ensure ongoing effectiveness and safety. Future sessions will further explore and process the client's traumatic experiences to reduce the intensity and frequency of distressing flashbacks. The therapeutic focus will also include reinforcing positive social interactions, like those with the client's foster children, which contribute to emotional well-being. Services remain medically necessary, and continued progress will be closely monitored. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 2/11/2025 at 10:51 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Score on GAD-7 (18) severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Neutral
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

He related these episodes to traumatic events from his past, specifically those stemming from growing up in a dysfunctional family. Despite these challenges, the Client expressed a commitment to utilizing his coping skills and noted variable improvements toward his treatment goals. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. Throughout the session, the Client appeared alert and engaged, demonstrating a willingness to discuss his ongoing struggles with chronic post-traumatic stress disorder and generalized anxiety disorder. His affect was congruent with the topics discussed, and his mood was generally stable though tinged with underlying anxiety when discussing his flashbacks. Physically, he appeared wellgroomed and maintained a consistent level of energy throughout the session. His speech was coherent and goal-directed, reflecting a clear understanding of the issues at hand. Behaviorally, the Client remained cooperative and actively participated in the therapeutic process, suggesting an internal motivation to manage his symptoms. He reported no new medical issues and confirmed compliance with his medication regimen, noting no adverse side effects.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Variable

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to improve but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The Client continues to present with symptoms consistent with his primary diagnosis of chronic post-traumatic stress disorder and secondary diagnosis of generalized anxiety disorder. His recent experiences with flashbacks and resultant sleep disturbances suggest ongoing challenges in managing his PTSD symptoms, particularly in response to situational stressors. Despite these difficulties, the Client continues to demonstrate progress in his therapeutic journey, as evidenced by his active use of coping strategies and his acknowledgment of variable improvements toward his treatment goals. The therapeutic modalities employed, including Cognitive Behavioral Therapy (CBT), Solution-Focused Brief Therapy (SFBT), Motivational Interviewing (MI), and psychoeducation, appear to be effective in facilitating this progress. The Client's continued engagement and motivation in therapy are positive indicators of his commitment to achieving long-term mental health stability.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals.

Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The plan for the Client's ongoing care involves maintaining the current therapeutic approach, with an emphasis on strengthening his coping mechanisms to manage flashbacks and anxiety symptoms more effectively. Continued use of CBT, SFBT, MI, and psychoeducation will be integral in addressing his trauma-related responses and enhancing his resilience. Regular monitoring of his sleep patterns and anxiety levels will be essential to tailor interventions as needed. The Client will be encouraged to maintain his medication regimen and to communicate any changes in symptoms or side effects promptly. Future sessions will focus on exploring deeper triggers of his flashbacks and developing strategies to mitigate their impact on his daily functioning and relationships. Services remain medically necessary, and the Client's ongoing participation in therapy will be crucial in fostering continued progress. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Weekly

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 3/11/2025 at 10:51 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Updated score on GAD-7 (14) moderate-severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Neutral
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a neutral mood and congruent affect. Client reported on events and feelings since their last session, which included that he continues to experience ongoing challenges related to chronic post-traumatic stress disorder and generalized anxiety disorder. He reported experiencing some flashbacks, which negatively impact his anxiety and distress symptoms. He believes these challenges continue to stem from traumatic memories of his upbringing in a toxic and abusive household, compounded by situational stressors such as financial difficulties and limited resources due to his disability. Despite these challenges, the client shared that he is focused on the things he can control and engages in activities that bring balance to his life, such as spending time with friends and foster kids, and writing short poems. He expressed that utilizing his coping skills has led to variable improvements towards his treatment goals. The client remains committed to his progress and continues to focus on managing his symptoms effectively. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. Throughout the session, the client appeared engaged and motivated to discuss his progress and challenges. He maintained a stable and appropriate affect, and his mood was generally positive, although he acknowledged experiencing distress when discussing flashbacks and financial stressors. Physically, he appeared well-groomed and attentive, with no signs of acute distress. His speech was coherent and articulate, allowing for a clear understanding of his experiences and ongoing efforts in therapy. The client demonstrated adaptive behavior by actively utilizing coping strategies and seeking activities that contribute to his emotional balance.

There were no new medical issues reported, and he confirmed medication compliance without experiencing any adverse side effects.

Client completed an updated GAD-7 and scored in the moderate-severe range (14), a decrease from the previous (18).

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Variable

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety remains elevated and continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is progressing in his therapeutic journey, with continued focus on managing symptoms of post-traumatic stress disorder and generalized anxiety disorder. His acknowledgment of flashbacks and their impact on his anxiety highlights areas where ongoing therapeutic interventions are necessary. The client's proactive efforts to engage in positive activities and utilize coping skills indicate resilience and a commitment to his treatment goals. His ability to articulate his experiences and actively participate in therapy sessions suggests a strong therapeutic alliance and a willingness to address underlying trauma and stressors. The primary therapeutic modalities of Cognitive Behavioral Therapy (CBT), Solution-Focused Brief Therapy (SFBT), Motivational Interviewing (MI), and psychoeducation remain effective in supporting his progress.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The plan is to continue utilizing CBT, SFBT, MI, and psychoeducation to support the client's progress. Client asked to have his treatment plan renewed. Therapy will focus on further developing and reinforcing coping strategies to manage flashbacks and anxiety symptoms. The client will be encouraged to maintain engagement in activities that promote emotional balance and explore additional strategies to address financial stressors and resource limitations. Follow-up sessions will continue to monitor his medication compliance and any potential side effects. The services remain medically necessary, and the therapeutic interventions will be adjusted as needed to align with his evolving needs and treatment goals. The client is encouraged to communicate any changes in symptoms or challenges between sessions to ensure appropriate support and intervention. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Every 2 Weeks

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 3/25/2025 at 10:56 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Updated score on GAD-7 (14) moderate-severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Euthymic
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a euthymic mood and congruent affect. Client reported on events and feelings since their last session, which included that he was having a generally good evening. He shared that he had been reflecting on the past week since his last appointment and was feeling optimistic about the trajectory of his treatment and progress. Client noted that this optimism continues to be inspirational for him. He acknowledged that although he continues to struggle with symptoms of distress and anxiety, he feels these are primarily due to situational stressors. These stressors are triggered by memories of past traumatic experiences during his childhood in an abusive and toxic family environment. Despite these challenges, Client reported feeling better since his last session, attributing this improvement to a recent connection that has helped him make progress in addressing some unresolved issues with his family. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. During the session, Client appeared engaged and motivated, displaying a hopeful demeanor. His affect was congruent with his expressed mood of optimism, and he articulated his thoughts clearly, indicating no cognitive impairments. Physically, Client showed no signs of distress, and his speech was coherent and at a normal rate and volume. His behavior throughout the session was cooperative and goal-oriented, as he discussed the use of coping skills and their positive impact. Client remains focused on his treatment goals, and he continues to utilize therapeutic modalities such as Cognitive Behavioral Therapy (CBT), Solution-Focused Brief Therapy (SFBT), Motivational Interviewing (MI), and psychoeducation. No new medical issues were reported, and Client confirmed medication compliance without experiencing any adverse side effects.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Improved

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to lessen but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. Client continues to make progress in his treatment for chronic Post-traumatic Stress Disorder (F43.12) and Generalized Anxiety Disorder (F41.1). His increased optimism and motivation indicate a positive shift in his mental health. The connection he made, which he believes is aiding in resolving past family issues, suggests that he is beginning to address some of the underlying causes of his trauma. Client's continued use of coping strategies is helping to mitigate the distress and anxiety triggered by situational stressors. While he acknowledges the ongoing struggle with these symptoms, his ability to reflect on his progress and remain hopeful is a significant marker of improvement. Services remain medically necessary to support his continued progress.

Plan

psychoeducation. The goal is to further strengthen his coping skills and support him in addressing unresolved issues related to his past trauma. Continued monitoring of his symptoms of distress and anxiety is essential to ensure that situational stressors are managed effectively. Client will also be encouraged to maintain medication compliance and report any changes in side effects. Future sessions will focus on maintaining the momentum of his progress and exploring additional strategies to enhance his resilience and emotional wellbeing. Regular follow-up appointments via video will be scheduled to ensure continuity of care. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Every 2 Weeks

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 4/2/2025 at 6:50 ᴘᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Updated score on GAD-7 (14) moderate-severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Euthymic
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a euthymic mood and congruent affect. Client reported on events and feelings since their last session, which included that he continues to experience ongoing issues with distress and anxiety. He attributed these feelings primarily to persistent flashbacks linked to his traumatic childhood experiences at the hands of his parents. Additionally, he noted stressors such as living on a fixed income and dealing with declining health, which exacerbate his mood and anxiety levels. The client also mentioned that the loss of sleep due to flashbacks and sleep disturbances continues to impact him negatively. Despite these challenges, he reported an overall sense of progress since his last session. He expressed confidence in utilizing his coping skills effectively and demonstrated engagement and focus on achieving his treatment goals. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. Throughout the session, the client appeared engaged and motivated, displaying a willingness to discuss his challenges and strategies for improvement. His affect was appropriate, and he maintained a cooperative demeanor. The client's mood appeared stable, although he acknowledged moments of increased anxiety and distress related to his flashbacks and current life stressors. Physically, he appeared well-groomed and showed no signs of acute distress. His speech was coherent and goal-directed, indicating a clear ability to articulate his thoughts and feelings. Behaviorally, he was attentive and actively participated in the therapeutic process, reaffirming his commitment to treatment.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Improved

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to lower but continues to meet criteria for GAD and PTSD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client continues to exhibit symptoms consistent with his primary diagnosis of chronic post-traumatic stress disorder (F43.12) and secondary diagnosis of generalized anxiety disorder (F41.1). He reported "some instances of distress and anxiety" linked to traumatic memories and current life stressors, including financial concerns and health issues. Despite these challenges, he "reported progress over his last session" and continues to employ coping strategies effectively. The therapeutic modalities of Cognitive Behavioral Therapy (CBT), Solution-Focused Brief Therapy (SFBT), Motivational Interviewing (MI), and psychoeducation remain beneficial in supporting his treatment goals. The client's motivation to improve and commitment to treatment are significant factors in his progression.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals.

Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The treatment plan will continue to focus on addressing symptoms of PTSD and anxiety through the ongoing use of CBT, SFBT, MI, and psychoeducation. Given the client's report of "variable progress," sessions will emphasize reinforcing coping skills and exploring additional strategies to manage distress and anxiety. The client will be encouraged to maintain medication compliance, as he reports no adverse side effects. Monitoring of sleep patterns and exploration of additional sleep hygiene techniques will be prioritized to address sleep disturbances. Regular assessment of stressors related to financial and health concerns will be incorporated into sessions to support overall well-being. Future sessions will focus on sustaining his motivation and commitment to achieving treatment goals. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Every 2 Weeks

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 4/16/2025 at 6:52 ᴘᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Updated score on GAD-7 (14) moderate-severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Neutral
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant video telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a euthymic mood and congruent affect. Client reported on events and feelings since their last session, which included that he has been doing better since his last appointment. He expressed that he continues to make progress in some areas of functioning and realizes tangible results from his efforts both inside and outside the therapy space. The client shared that he is actively utilizing his learned coping skills and is focusing on aspects of his life over which he has some influence and control. He emphasized that he is directing his attention towards the positive aspects of his life rather than the negative ones. The client remains committed to his treatment goals, which include learning coping techniques to reduce PTSD symptoms and preparing to handle future stressful situations. He reported no new medical issues and confirmed medication compliance without experiencing any adverse side effects. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. During the session, the client appeared engaged and was able to articulate his thoughts and feelings clearly via video. He demonstrated a stable mood and affect that were congruent with the positive progress he described. His speech was normal in rate and tone, and he maintained appropriate eye contact through the video platform. The client exhibited behaviors consistent with someone who is committed to their therapeutic process, such as actively discussing coping strategies and reflecting on his progress. There were no observable physical symptoms of distress, and he appeared well-groomed and attentive throughout the session. These observations suggest that the client is utilizing therapeutic tools effectively and remains motivated in his treatment.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Improved

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to lower but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is progressing in his treatment for chronic PTSD and generalized anxiety disorder. His ability to apply coping skills and maintain a focus on controllable factors and positive aspects of his life indicates a positive trajectory in his mental health. Continued commitment to his treatment goals and reported medication compliance without adverse effects further support this assessment. The primary therapeutic modalities being utilized include Cognitive Behavioral Therapy (CBT), Solution-Focused Brief Therapy (SFBT), and psychoeducation. These approaches appear to be beneficial in helping him manage his symptoms and prepare for future stressful situations. Services remain medically necessary to support his ongoing progress and to address any potential challenges that may arise.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The treatment plan will continue to focus on reinforcing the client's coping skills and stress management techniques. Future sessions will include further exploration of thought stopping, thought switching, creative visualization, progressive muscle relaxation, and deep breathing exercises as part of his stress inoculation training. The client will be encouraged to maintain his focus on positive aspects of life and to continue applying learned coping strategies in daily situations. Regular monitoring of medication compliance and any potential side effects will remain a priority. The next session will aim to build on the client's current progress and address any new challenges he may encounter. Follow-up appointments will be scheduled as per the client's treatment plan to ensure continued support and progression. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Every 2 Weeks

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 4/30/2025 at 6:51 ᴘᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Updated score on GAD-7 (14) moderate-severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Euthymic
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant video telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a euthymic mood and congruent affect. Client reported on events and feelings since their last session, which included that he continues to experience some distress and anxiety symptoms. He mentioned feeling "overall better since the last appointment" and acknowledged making "some progress." However, he continues to experience problems with flashbacks, which negatively impact his functioning and contribute to sleep disturbances. These disturbances are linked to traumatic experiences growing up in what he describes as a “crime family,” due to his parents' activities. The client shared that spending time with his children is uplifting and provides motivation to press forward. He remains committed to his treatment goals and actively utilizes coping skills, noting improvements while recognizing areas still needing focus. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. During the session, the client's affect appeared congruent with the content discussed, and his mood was noted as hopeful yet understandably concerned about his flashbacks. Physically, he presented as well-groomed and alert, with no signs of distress observable in the video setting. His speech was coherent, with a normal rate and volume, and his behavior was cooperative and engaged throughout the session. The client reported medication compliance and did not mention any adverse side effects or new medical issues. The therapeutic modalities employed included Cognitive Behavioral Therapy (CBT), Solution-Focused Brief Therapy (SFBT), Motivational Interviewing (MI), and psychoeducation, which seemed to support his ongoing progress.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Improved

Assessment / Additional Notes

Services remain medically necessary due to the persistent nature of his symptoms and their impact on his functioning.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The treatment plan will continue to focus on managing PTSD and GAD symptoms, with an emphasis on reducing the frequency and intensity of flashbacks. The client will continue engaging in CBT, SFBT, MI, and psychoeducation to strengthen coping mechanisms and enhance emotional regulation. He will be encouraged to maintain medication adherence and monitor for any potential side effects. The therapist will support the client in exploring additional strategies to address sleep disturbances and improve overall sleep hygiene. Regular follow-up appointments will be scheduled to monitor progress, address any emerging concerns, and adjust the treatment plan as needed. The client will be encouraged to continue leveraging the positive impact of spending time with his children while working towards his therapeutic goals. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Every 2 Weeks

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 5/14/2025 at 6:52 ᴘᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Updated score on GAD-7 (14) moderate-severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Neutral
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant video telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a neutral mood and congruent affect. Client reported on events and feelings since their last session, which included that he continues to struggle with distress and anxiety, attributing most of these feelings to current stressors linked to his flashbacks. He recounted traumatic memories from his childhood, describing it as growing up in a “crime family” with incidents involving missing children over several years. The client shared his frustration with law enforcement and other agencies, perceiving them as not taking his accounts seriously or doing enough to address the issues he raised. He continues to process these memories through journaling, which he reported has recently helped him gain more information in two cases. Despite these challenges, the client remains hopeful about his future prospects and continues to rely on his support system for encouragement. He expresses commitment to utilizing the tools he is learning in therapy and acknowledges seeing some improvements, though he recognizes the need to focus on specific areas of functioning. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary.

Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. The client appears engaged and motivated during the session, demonstrating a consistent effort to work through his traumatic memories and anxiety. His affect is congruent with the topics discussed, and he maintains a stable mood throughout the session. Physically, he does not report any new medical issues, and there are no observable signs of distress during the video call. His speech is clear and coherent, allowing for effective communication of his thoughts and feelings. Behaviorally, the client continues to engage actively with his treatment plan, utilizing therapeutic techniques such as journaling, which have been beneficial. He demonstrates an understanding of the coping strategies discussed in therapy, as evidenced by his continued application of these tools in managing his symptoms.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Variable

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to lower but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is progressing in his treatment, as indicated by his ability to reflect on his experiences and utilize coping strategies effectively. His primary diagnosis of chronic post-traumatic stress disorder manifests through ongoing flashbacks and anxiety related to his childhood trauma. Additionally, the secondary diagnosis of generalized anxiety disorder is evident in his reported struggles with distress and anxiety. The client’s frustration with law enforcement and other agencies suggests a need for further exploration of these feelings in therapy. His ongoing journaling efforts highlight a proactive approach to processing his memories, contributing to his therapeutic progress. The use of therapeutic modalities such as CBT, SFBT, MI, and psychoeducation appears to be supporting his treatment goals, fostering a sense of hope and empowerment.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. Continued focus on the client’s treatment goals will be emphasized in upcoming sessions, with a particular emphasis on further developing and refining his coping skills. The therapeutic approach will continue to incorporate CBT, SFBT, MI, and psychoeducation to address his PTSD and anxiety symptoms. Exploration of the client’s frustration with law enforcement and agencies will be prioritized to help him process these feelings and develop strategies for managing them. Encouragement to maintain his journaling practice will be provided, as it has proven beneficial in gaining insights and processing traumatic memories. Regular check-ins on his support system usage and its effectiveness will be conducted to ensure he has adequate encouragement and motivation. The next session will aim to build on the progress made, reinforcing the use of therapeutic tools and addressing any emerging challenges. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Every 2 Weeks

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 5/28/2025 at 6:52 ᴘᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Updated score on GAD-7 (14) moderate-severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Neutral
Affect:	Congruent
Insight:	Good
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant video telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a neutral mood and congruent affect. Client reported on events and feelings since their last session, which included that he has been "feeling and doing better overall" despite continuing to struggle with flashbacks associated with his traumatic childhood. These flashbacks have been affecting his sleep, yet he finds that journaling his thoughts after each event has been beneficial. This strategy, along with other coping skills, supports him in managing some of the lingering effects of his PTSD. He also noted that he is reaching out to his foster children and other supportive individuals, which provides motivation in his healing journey. While this support is helpful most days, he sometimes experiences feelings of loneliness, isolation, and lack of motivation, though he strives to focus on aspects of his life he can control. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. During the session, the client appeared engaged and committed to his treatment goals, as evidenced by his consistent use of coping strategies. He demonstrated an understanding of the importance of these techniques in managing his symptoms, including anxiety and distress, which he reports have been gradually improving. There were no new medical issues reported, and the client continues to comply with his medication regimen without experiencing adverse side effects. The primary therapeutic modalities utilized in his treatment include Cognitive Behavioral Therapy (CBT), Solution-Focused Brief Therapy (SFBT), Motivational Interviewing (MI), and psychoeducation. His speech was coherent, and his mood appeared stable, though intermittently affected by the flashbacks and associated sleep disturbances. His affect was congruent with the content of his discussions, reflecting his ongoing efforts and challenges in his recovery process.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Improved

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to lessen but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is progressing in his treatment, as evidenced by his proactive utilization of coping skills and his continued engagement with supportive individuals. The persistence of flashbacks and sleep disruptions indicates the chronic nature of his PTSD, yet his ability to manage these episodes through journaling and other strategies highlights his resilience. His acknowledgment of feeling alone and unmotivated at times suggests areas where additional support and therapeutic focus could be beneficial. The client’s anxiety levels, while still present, are reportedly improving, which aligns with his overall sense of progress. His motivation to remain focused on treatment goals and his understanding of the need to enhance certain areas of functioning are positive indicators of his commitment to recovery.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The plan is to continue utilizing CBT, SFBT, MI, and psychoeducation to address the client’s PTSD and anxiety symptoms. Emphasis will be placed on exploring and reinforcing coping mechanisms that effectively mitigate the impact of flashbacks and sleep disturbances. Further exploration of feelings of isolation and lack of motivation will be conducted to develop additional strategies for support. Encouragement will be given for the client to maintain his journaling practice and to continue reaching out to supportive individuals in his network. Regular assessment of medication efficacy and side effects will be maintained to ensure continued compliance and effectiveness. Ongoing monitoring of the client's progress in therapy will be essential, with adjustments to the treatment plan as necessary to meet evolving needs and goals. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Every 2 Weeks

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 6/11/2025 at 6:52 ᴘᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Updated score on GAD-7 (14) moderate-severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Euthymic
Affect:	Congruent
Insight:	Excellent
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant video telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a euthymic mood and congruent affect. Client reported on events and feelings since their last session, which included that he was having a good evening and was enjoying the company of one of his adult foster children. He reflected on a recent poem and journal entry he completed following a flashback associated with his childhood trauma. The client described his upbringing as "growing up in a crime family," which he believes drastically impacted his development and current level of functioning. Despite the challenges he is facing, he is trying to remain positive. He acknowledged feeling overwhelmed at times but expressed a belief that things will soon improve. He continues to utilize his coping and journaling skills as part of his strategy to manage his symptoms. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. Throughout the session, the client appeared engaged and communicative during the video session. He spoke clearly about his experiences and reflections, demonstrating insight into his current challenges and coping mechanisms. The client indicated that he leans on his limited support system for motivation and inspiration, although he acknowledged that maintaining these relationships is not always easy due to existing strains. He is working on his patience, especially in interactions with his brother and children. The client continues to report medication compliance with no adverse side-effects, and no new medical issues were noted. His affect was congruent with his reported mood, and his speech was normal in rate and volume.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Improved

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to improve but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is progressing in his treatment for chronic post-traumatic stress disorder and generalized anxiety disorder. His engagement in reflective activities like journaling and poetry writing suggests an adaptive response to his flashbacks and childhood trauma. The client's ability to identify and articulate his feelings of being overwhelmed, while maintaining hope for improvement, indicates a level of resilience. His willingness to work on family relationships, despite existing tensions, shows a commitment to improving his interpersonal dynamics. The therapeutic interventions being utilized, including CBT, SFBT, MI, and psychoeducation, remain appropriate and beneficial. The client's ongoing medication compliance, without adverse effects, supports the stability of his current treatment plan.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals.

Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The plan is to continue with the current therapeutic approach, employing CBT, SFBT, MI, and psychoeducation to support the client's ongoing progress. Emphasis will be placed on reinforcing his coping strategies and encouraging further reflective practices like journaling and poetry. The client will be encouraged to continue leveraging his support system, while also exploring ways to enhance these relationships. Efforts will be made to address the client's feelings of being overwhelmed, possibly through additional stress management techniques. The client will be monitored for any changes in his mental health status and medication side effects. The services remain medically necessary, and the client will be scheduled for regular follow-up sessions to ensure ongoing support and assessment of his progress. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Every 2 Weeks

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 6/25/2025 at 7:15 ᴘᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Updated score on GAD-7 (14) moderate-severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Euthymic
Affect:	Congruent
Insight:	Excellent
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant video telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a euthymic mood and congruent affect. Client reported on events and feelings since their last session, which included that he was feeling better overall and expressed a sense of progress toward his treatment goals. Despite acknowledging that his symptoms can still be exacerbated at times, he actively utilizes his learned coping skills to manage them effectively on most days. The client noted a focus on the positive aspects of his life and remains committed to identifying areas for improvement. He shared a hopeful perspective about his future and believes his efforts, both within and outside the therapeutic setting, are yielding positive outcomes. The client continues to report medication compliance and experiences no adverse side effects. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. During the session, the client presented as engaged and cooperative. His speech was clear and coherent, and his mood appeared optimistic with an appropriate affect. He demonstrated insight into his condition and motivation to continue working toward his goals. The client showed no signs of distress during the session, and there were no reports of new medical issues. His physical presentation appeared normal, with no notable changes in behavior. The client continues to benefit from the therapeutic modalities being employed, including Cognitive Behavioral Therapy (CBT), Solution-Focused Brief Therapy (SFBT), Motivational Interviewing (MI), and psychoeducation.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Improved

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to lower but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is progressing in managing his primary diagnosis of chronic post-traumatic stress disorder and secondary diagnosis of generalized anxiety disorder. He continues to implement coping strategies effectively, which contributes to symptom mitigation. The client's motivation and proactive approach to treatment are evident in his continued focus on positive life aspects and areas for improvement. His hopeful outlook and belief in the efficacy of his efforts both in therapy and independently suggest a positive trajectory. The therapeutic interventions remain appropriate and beneficial, supporting the client's ongoing progress.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The plan is to continue with weekly video sessions to support the client's ongoing progress and address any emerging challenges. The therapeutic focus will remain on reinforcing coping strategies and expanding the client's positive outlook. The client will continue to engage in CBT, SFBT, MI, and psychoeducation to enhance his management of symptoms and support his treatment goals. Monitoring medication compliance and any potential side effects will be ongoing to ensure the client's safety and well-being. Encouraging the client to maintain his motivation and proactive approach will be essential in sustaining his progress. Services remain medically necessary to support the client's continued improvement. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Every 2 Weeks

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 7/9/2025 at 6:52 ᴘᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Updated score on GAD-7 (14) moderate-severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Neutral
Affect:	Congruent
Insight:	Excellent
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant video telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a neutral mood and congruent affect. Client reported on events and feelings since their last session, which included that he continues to experience some symptoms associated with distress and anxiety. He shared that he is utilizing his coping skills to try and mitigate any problems, sometimes with varying results, but he feels like he is seeing some progress in his overall functioning. The client expressed that he continues to remain hopeful, motivated, and dedicated to his treatment goals, understanding the importance of remaining steadfast in his efforts both inside and outside of therapy sessions. He mentioned experiencing flashbacks due to his traumatic childhood experiences, acknowledging that while they can be emotionally and physically draining, they are part of the healing process. After these episodes, he finds that he is able to process with more clarity, which offers him some relief. The client also noted that he continues to lean on his adult children for additional support and engages with others in coffee shops, which provides him a sense of relief. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. During the session, the client appeared engaged and attentive, participating actively through the video format. His speech was clear and coherent, with a normal rate and volume. The client maintained a stable mood throughout the session, demonstrating a generally positive outlook despite the ongoing challenges he faces. Affect was congruent with his reported feelings of hopefulness and motivation. Physically, the client did not report any new medical issues and stated that he maintains medication compliance without adverse side effects. His behavior was consistent with previous sessions, showing a dedication to utilizing therapeutic strategies and engaging in the therapeutic process.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Variable

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to lessen but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is progressing in treatment, as evidenced by his reported use of coping skills and the relief he finds after processing flashbacks. His ongoing engagement with support systems, such as his adult children and social interactions at coffee shops, contributes positively to his mental health. The client’s understanding of the therapeutic process and his commitment to remaining steadfast in his efforts are indicative of his motivation to achieve his treatment goals. The continued use of therapeutic modalities, including CBT, SFBT, MI, and psychoeducation, remains appropriate and beneficial for addressing his symptoms of chronic post-traumatic stress disorder and generalized anxiety disorder.

Services continue to be medically necessary to support the client’s mental health and well-being.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. The plan is to continue the current therapeutic approach, focusing on enhancing the client’s coping skills and processing techniques. Sessions will maintain the use of CBT, SFBT, MI, and psychoeducation to address the client’s symptoms and promote further progress. The client will be encouraged to continue engaging with his support network and participating in activities that offer him relief and enjoyment. Monitoring of medication compliance and potential side effects will continue, ensuring that any issues are addressed promptly. The client will be supported in maintaining his motivation and dedication to therapy, with regular check-ins on his progress and any challenges he faces. Future sessions will aim to build on the progress made and further empower the client in managing his symptoms effectively. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Every 2 Weeks

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 7/24/2025 at 11:55 ᴀᴍ.

Diagnosis

F43.12 Post-Traumatic Stress Disorder, Chronic

F41.1 Generalized Anxiety Disorder

Updated score on GAD-7 (14) moderate-severe, clinical orientation, and historical data.

Current Mental Status

Orientation:	X3: Oriented to Person, Place, and Time
General Appearance:	Appropriate
Dress:	Appropriate
Motor Activity:	Unremarkable
Interview Behavior:	Appropriate
Speech:	Normal
Mood:	Euthymic
Affect:	Congruent
Insight:	Excellent
Judgment/Impulse Control:	Excellent
Memory:	Intact
Attention/Concentration:	Good
Thought Process:	Unremarkable
Thought Content:	Appropriate
Perception:	Unremarkable
Functional Status:	Intact

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Medications

Reported being prescribed Clonazepam 2 mg tablet PRN and Buspirone 15 mg tab once daily.

Subjective Report and Symptom Description

Met with 55-year-old White male with a history of anxiety and trauma for his individual follow-up therapy session via a HIPAA compliant video telehealth platform. Documents and forms were reviewed. Client was on time for his session. His preferred name is "Happy". Client reported being in Texas, in a private setting. He was cooperative and presented as oriented X3, with a euthymic mood and congruent affect. Client reported on events and feelings since their last session, which included that he continues to see some progress in his life, particularly in the areas of functioning and in the intensity of his flashbacks. He is actively processing his traumatic childhood memories by journaling, writing poems, and short stories. The client reported no mood swings or rapid cycling, expressing a sense of stability by stating that he feels like he’s doing okay. However, he remains stressed about his current financial situation, as he is disabled and reliant on a fixed income. He expressed concern about the possibility of losing some or all of his benefits due to recent policy changes at the federal level, which may affect eligibility and duration. Despite these stressors, the client is trying to focus on the positives and let go of things beyond his control. Therapist used interventions listed below with the client being responsive to them. Some progress was made. Therapist and client continued to explore and discuss relevant content for the remainder of the session with therapist validating the client’s emotions and challenging maladaptive thoughts when necessary. Client asked to be scheduled for their next 1:1 session.

Objective Content

The client was dressed appropriately and attending to their ADL’s. Client’s voice, tone, volume, range, and inflection were all within normal range with no evidence of psychosis and/or mania. Client was future/goal oriented and voiced no suicidal/homicidal ideations; no distress was noted. No acute safety issues were identified during today's appointment. Client acknowledged they have access to numbers for crisis intervention provided during the intake. Client agreed to speak with a family member or friend, call clinic (not use Client portal) if it's during business hours, utilize crisis intervention numbers, or call 911 if they experience unsafe thoughts (e.g., SI or HI) or have an urgent or emergent matter. During the session, the client demonstrated a stable mood and affect, appearing calm and engaged throughout the video call. His speech was coherent and goal-directed, indicating active participation in the therapeutic process. Physically, no new medical issues were reported, and the client appeared well-groomed and attentive. Behaviorally, he continues to utilize coping skills effectively, which helps mitigate any rise in symptomatology, as observed through his consistent engagement in therapy and self-reporting of progress. He is actively working with therapeutic interventions such as Cognitive Behavioral Therapy (CBT), Solution-Focused Brief Therapy (SFBT), Motivational Interviewing (MI), and psychoeducation. The client reported medication compliance with no adverse side effects.

Interventions Used

Treatment Plan Progress

Objectives

1. Emotion regulation.

Identity and sense of self.

Relationships.

What causes CPTSD?

Examples of these types of traumatic situations include:

Prolonged domestic violence.

Childhood sexual or physical abuse.

Torture.

Genocide.

Slavery.

Psychotherapy (talk therapy) is the main treatment for complex PTSD. Specifically, this type of psychotherapy is a form of cognitive behavioral therapy (CBT) called trauma-focused CBT.

Trauma-focused CBT involves:

Learning how your body responds to trauma and stress.

Learning how to manage symptoms.

Identifying and reframing problematic thinking patterns.

Exposure therapy.

Progress: Improved

Assessment / Additional Notes

Based on the client’s reports and in-session observations, the client’s level of distress/anxiety continues to improve but continues to meet criteria for PTSD and GAD. Client appears to respond well to CBT, Motivational Interviewing and SFBT. The client is progressing in managing his symptoms related to chronic post-traumatic stress disorder and generalized anxiety disorder. His engagement in therapeutic activities such as journaling and writing is helping him to process his traumatic memories, and he appears to be making meaningful strides in reducing the intensity of flashbacks. His ability to maintain stability in his mood and utilize coping strategies demonstrates growth and resilience. While he is experiencing stress related to financial concerns and potential policy changes, he is actively working to focus on aspects of his life that he can control. The client remains compliant with his medication regimen, which continues to support his therapeutic progress.

Plan

It is recommended that client meet with therapist for their ongoing sessions and continue working towards their identified treatment goals. Continuing with the current treatment modalities is recommended, as the client responds positively to CBT, SFBT, and MI. Continue to provide support through regular therapy sessions focusing on CBT, SFBT, MI, and psychoeducation to help the client process trauma and manage anxiety. Encourage the client to maintain his journaling and creative writing practices as therapeutic outlets. Monitor his stress levels related to financial concerns and explore potential resources or support systems that may assist him in navigating changes in benefits. Reinforce the use of effective coping skills to manage stress and anxiety. Continue to assess the client's medication compliance and any potential side effects in collaboration with his prescribing provider. Services remain medically necessary to support the client's ongoing progress and stability. Client agreed to contact the clinic if a sooner appointment is needed and/or any other concerns arise before the next scheduled follow-up.

Recommendation: Continue current therapeutic focus

Prescribed Frequency of Treatment: Every 2 Weeks

Roberto Guerrero, LPC, Licensed Professional Counselor, License 79242, signed this note and declared this information to be accurate and complete on 8/6/2025 at 6:55 ᴘᴍ.

CPTSD THERAPY NOTES 2024

Current Mental Status

Medications

Subjective Report and Symptom Description

Interventions Used

Treatment Plan Progress

Objectives

Plan

Current Mental Status

Medications

Subjective Report and Symptom Description

Interventions Used

Treatment Plan Progress

Objectives

Plan

Current Mental Status

Medications

Subjective Report and Symptom Description

Interventions Used

Treatment Plan Progress

Objectives

Plan

Current Mental Status

Medications

Subjective Report and Symptom Description

Interventions Used

Treatment Plan Progress

Objectives

Plan

Current Mental Status

Medications

Subjective Report and Symptom Description

Interventions Used

Treatment Plan Progress

Objectives

Plan

Current Mental Status

Risk Assessment

Suicidal ideation (Low Risk)

Subjective Report and Symptom Description

Objective Content

Interventions Used

Treatment Plan Progress

Objectives

Assessment / Additional Notes

Plan

Diagnosis

Current Mental Status

Subjective Report and Symptom Description

Objective Content

Interventions Used

Treatment Plan Progress

Objectives

Assessment / Additional Notes

Plan

Diagnosis

Current Mental Status

Subjective Report and Symptom Description

Objective Content

Interventions Used

Treatment Plan Progress

Objectives

Assessment / Additional Notes

Plan

Diagnosis

Current Mental Status

Subjective Report and Symptom Description

Objective Content

Interventions Used

Treatment Plan Progress

Objectives

Assessment / Additional Notes

Plan

Diagnosis

Current Mental Status

Subjective Report and Symptom Description

Objective Content

Interventions Used

Treatment Plan Progress

Objectives