Sample Reports
Progress Report SLF Training
Progress Report (Post-session #4) From:
(Add your name and title) Arete Human Resources Suite 210, 8180 Macleod Trail S Calgary, AB, T1H 2B8 Telephone: 1-888-255-5196 ext Fax: 1-403-252-6161
AUTOPOPULATED CLAIMANT Mr John Doe CONTROL # 12345-00678-00 ADDRESS 1001 Nowhere St. D.O.D. December 10, 2012 EMPLOYER Canada Post
D.O.B. POLICY # PHONE C.O.D. ACM
DIAGNOSIS
depressive episode
OCCUPATION
DATE of 4th SESSION REPORT DATE
March 21, 2013
REFERRAL DATE
March 2, 1960 12345 987-654-3210 March 10, 2015 Ms Smith phone 123-456-7890 letter carrier February 12, 2013
March 22, 2013
Arete Client Code: 12345
Professional ID: abcd
Therapists Estimate of RTW start date within the next 4 weeks (M/D/Y) (if changed since initial report, please provide explanation)
April 20, 2013. Client had a few setbacks that caused relapse, these have been addressed. Conflict will be discussed with employer and case manager on April 10, 2013 90%
Therapists Estimate of Client’s probability of successful RTW within next 4 sessions (%): ( if changed since initial report, please provide explanation)
388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235 www.banyanconsultants.com
Page |2 Resolved Barriers since Initial report Barrier mentioned in initial report
Comments/Explanation (if needed)
1) poor daily rhythm
client is able to get up at 9 am every day and intends to move this up with 30 minutes per week, client eats three healthy meals per day and goes to bed at 11 pm, client has a more or less regular daily rhythm with walks and household chores
2) poor self-care
client gets dressed every day and takes a shower every other day
3) poor physical stamina
client is consistent in following the exercise program and has improved physical stamina
Ongoing Barriers to RTW (defined by therapist and discussed with client) Summary of current ongoing barriers (may include symptoms, life circumstance, workplace issues, addiction history or any other influencing factors) 1) sleeping problem still existing barrier
Impact Severity (1)Mild (2)Moderate (3)Severe & Serious
Observations of impact on RTW/ Solutions
Current treatment plan
moderate
regular daily rhythm helps further restore sleeping pattern and focus
2) conflict at work still existing barrier
severe
client would still not be able to get up and start working at 6 am, but is improving conflict needs to be discussed at work prior to RTW
3) poor support network still existing barrier
mind
client expects to return to work and find support network there
client could not think of any activity to restore his support network, other than finding contacts at work
4) financial problems new barrier
moderate
client worries that he is not able to pay child support and ex-wife will sue him, however when he starts RTW income will be higher Additional Comments: Client has not been in touch with
meeting is scheduled on April 10, 2013
discussed how he can approach ex-wife and explain that he is currently not able to pay all child support until back at work
coworkers since DOD
388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235 www.banyanconsultants.com
Page |3 Analysis of Job Tasks (based on therapist discussion with client) Main tasks
Duration Freq.
Feasibility 1----3-----5
Explanation
1. sorting mail
2-3 hrs
once per day
2-3
focus has improved but would still need additional time to do sorting without mistakes, would also find it hard to be around coworkers in a noisy environment
2. delivering mail
5 hrs
once per day
3
physical stamina has improved but could currently not walk for 5 hours still experiences difficulties in dealing with people
Ancillary tasks 1. helping out co-workers 5 with lifting mail containers minutes
5 times per day
3-4
depends on weight container
2. participating in meetings
1 hour
once per month
4-5
could not be around so many people and focus on meeting
3. asking customer signature for priority mail
5 minutes
once per week
3-4
still experiences difficulties with dealing with people
Feasibility of the task between 1 and 5, where a “5” means that it is not feasible, and “1” means that it is easy to perform at the current level of psychological complaints.
Which homework tools have you utilized with client?
Stress Inventory
Yes was helpful
Worrying assignment
Yes client used worrying assignment to work on ruminating over conflict and financial issues, was helpful
Time management
Yes / No
Rationale tool
Yes used in the first session to clarify balance in life and issues that need to be worked on
388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235 www.banyanconsultants.com
Page |4
Writing/Journaling assignment
Yes, client is using this instrument and finds it helpful in preventing ruminating
Anti-depressant skills
Yes / No
Handouts Managing Anger, Managing Worry, Relationship building, Relaxation Skills
Yes, managing worry and relationship building
Other
Please List: thought records
If you have not used home work tools, please provide explanation and suggestions
if Yes, name which handout
Which other tools have you used in preparing client for RTW and increasing RTW self-efficacy? Practiced role play for conversation with ex-wife about child support and practiced role play for meeting at work to address conflict
Client treatment evaluation Client’s Progress in Resolving barriers to RTW: (please provide evaluation) None Low Moderate Good Very Good 0________________________________5_x____________________________10 Evaluation/suggestions: client has not yet improved to the extent that he can start a RTW in own job, sleeping problem is still existing and conflict is not yet addressed Client’s Level of Engagement in Resolving barriers to RTW: (provide explanation/suggestions for improvement) None Low Moderate Good Very Good 0________________________________5____x__________________________10 Explanation/suggestions for improvement: client has participated in restoring daily rhythm, online diary and exercise program but has not been able to find a support network Client’s progress with self efficacy efforts: (please provide evaluation and suggestions for improvement) None Low Moderate Good Very Good 0_________________________________5______x________________________10 Evaluation/suggestions: through role play client feels more confident in addressing
388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235 www.banyanconsultants.com
Page |5 conflict and through thought records client feels more confident in solving unhelpful thinking Rate the progress in increasing client’s overall functioning thus far: (please provide explanation and suggestions for improvement) None Low Moderate Good Very Good 0_________________________________5__x_____________________________10 Explanation/suggestions for improvement: improved daily rhythm and daily activities Has client worked with the online diary? (if not daily, please provide explanation and suggestions) Not at all Half of Time Daily 0_________________________________5____________________x__________10 Explanation/suggestions for improvement: none Has client participated in the individual exercise program or increased physical activity otherwise? (if not daily, please provide explanation and suggestions) Not at all Half of Time Daily 0_________________________________5__________________x______________10 Explanation/suggestions for improvement: none
Update/Restatement of Therapeutic Treatment Plan to Achieve RTW Outcome (Summarize the key elements that will constitute the focus for therapy and the anticipated outcome) Consider options like: Bolster Self Management skills (i.e.: exposure exercises, etc) , Modified duties (to be explored), Suggested Modified Hours, Conflict resolution, Medication review/ medication management, improve physical stamina or improve daily routine (eating/ sleeping/activities) Goal
Method
Estimated timeframe
Who is involved
1. Client needs to further restore daily rhythm and sleeping pattern
Diary and exercise program are assisting him Has improved but needs further improvement
3-4 weeks
client and therapist
388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235 www.banyanconsultants.com
Page |6 2. Discussed client still finds it hard to find solutions for building a support network
Client will continue to think about this and we will continue in next sessions Client needs to continue going out and talking to people appointment with employer is scheduled on April 10, 2013
3-4 weeks
client and therapist
2 weeks
client and employer
4. RTW needs to be very gradual maybe with a work trial preceding to make sure that client can have positive experiences
creating gradual GRTW schedule with feasible job tasks see information in problem analysis
3-4 weeks , GRTW scheduled to start April 20, 2013
case manager and employer
5. Client needs to work on catastrophic thinking
Thought records to assist client in recognizing patterns of unhelpful thinking and behavior, needs to continue doing this to establish new thinking pattern
3-4 weeks
client and therapist
6. Address financial problem
When client returns to work, financial problems will diminish, not sure if there are alternate options to assist client?
3-4 weeks, GRTW scheduled to start April 20, 2013
Client, employer? Case manager?
3. Conflict needs to be discussed prior to starting RTW,
ex-wife?
Client discussed issue with exwife to be flexible in child support
388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235 www.banyanconsultants.com
Page |7 Specific Input for RTW Coordinator or Case Manager (elements that need to be addressed/considered based on consideration of barriers and job task analysis)
Conflict needs to be addressed
RTW needs to start with feasible job tasks, later start and preceded by work trial
Are there alternate options to assist client with financial issues?
388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235 www.banyanconsultants.com