Free Therapy Process Note Template
Therapy Note
Client Information
Client ID: EW13256
Name: Ethan Wilson
Age: 40
Session Date: September 30, 2050
Session Time: 10:00 AM to 11:00 AM
Presenting Issues
Ethan presented with continued discomfort and limited mobility in his right lower leg, despite ongoing physiotherapy efforts. He expressed frustration with the slow progress and concern regarding his overall recovery.
Observations and Assessments
Observations revealed Ethan continues to favor his left leg due to pain and stiffness in his right. His mobility has improved slightly compared to our last session; however, it is evident the progress is not meeting his expectations which appears to contribute to his ongoing feelings of frustration and impatience.
Therapeutic Interventions and Client's Response
The session focused on employing new physiotherapy techniques for pain management and improving mobility. These techniques included targeted muscle exercises and stretches. Ethan was cooperative and engaged during the session, although he expressed concerns about the effectiveness of therapy. Despite his initial hesitations, he acknowledged a slight reduction in his discomfort level by the end of the session.
Plan for Future Sessions
Continue with the new physiotherapy techniques while managing Ethan's expectations. It is crucial to ensure he understands the importance of patience throughout his recovery process. Regular reassessments will be made to monitor his progress and adjust his therapy plan accordingly.
Therapist's Comments
Given Ethan's frustration about his recovery speed, it may be beneficial to introduce psychological support into his treatment plan. His mental well-being is as important as his physical recovery in this journey.
