Note Examples
Example of Play Therapy Note

Example of Play Therapy Note

SUBJECTIVE

Presentation:

  • Chief Complaint: Client is a 6 year old female referred by parents for behavioral issues including defiance, tantrums, and aggression towards peers. Parents report these behaviors are impairing client's functioning at home and school.
    • Quote (Chief Complaint): "She just explodes into these huge tantrums where she's yelling, kicking, and hitting. It happens over the smallest things." - Client's mother
  • Impairments And Challenges: Per parents' report, client's behaviors are significantly impairing her functioning at home and school. She gets sent to time-out multiple times per week at school and has been suspended twice this year for hitting classmates. Her tantrums disrupt family routines and parenting of her younger sibling. Parents feel unable to take her many places due to her unpredictable outbursts.
    • Quote (Impairments And Challenges): "We can't even go to the grocery store as a family anymore without her melting down." - Client's father

OBJECTIVE

  • Type Of Play: Today's session utilized nondirective, child-centered play therapy. Client engaged in pretend play with dolls, toy cars and blocks.
  • Materials Used: Client used dolls, dollhouse, blocks, toy cars, and art supplies during today's session. She expressed preference for playing with the dolls and dollhouse.
  • Play Narrative And Symbolic Themes: Several concerning themes emerged in client's play. She had the dolls yell at each other frequently and hit or kick when angry. Punishment involved time-out or taking toys away. The play suggests client is experiencing anger/aggression and harsh discipline at home. Her play actions appear to be re-enacting situations at home.

ASSESSMENT

Progress And Response:

  • Response To Treatment: Client has attended 3 sessions to date. She is beginning to demonstrate more imaginative play and less resistance to therapist prompts or engagement. Rapport is building gradually.
  • Specific Examples Or Instances: Client remained engaged in play for nearly the full 45 minute session today with minimal redirection needed. She also shared stories about her family members through play.
  • Challenges To Progress: Client continues to display concerning aggressive themes during play. Additional rapport building is needed before directly addressing her behaviors.
  • Therapist Observations And Reflections: Concerning family dynamics around anger management and discipline appear to be impacting client's behavioral issues. Will need increased focus on teaching emotional regulation skills once rapport is more established.

PLAN

Discussed Goals:

Goal 1:

  • Goal Description: Client will learn and practice healthy emotional expression and regulation through play.
  • Metrics: Progress will be tracked by instances of client engaging in play scenarios that depict positive emotional expression, self-soothing, or problem-solving.
  • Attainability: Goal is attainable through modeling and role play during play therapy. Parent coaching can reinforce skills at home.
  • Relevance: Goal is highly relevant given impairment of behaviors at home and school. Will target root cause.
  • Time frame: Check progress towards emotional regulation goals weekly during play sessions over the next 3 months.
    • Quote (Goal): "I want her to be able to control herself when she gets upset instead of exploding and hitting." - Client's mother

Barriers To Achieving Goals: Lack of parental follow-through with recommendations could impede client's progress. Harsh parental discipline styles may also undermine emotional regulation skills.

Follow Up Actions And Plans:

  • Homework: Client will role play 2-3 coping strategies during session that she can practice using at home when feeling upset. Parents will praise use of strategies.
  • Plan For Future Session: Future sessions will focus on building skills for identifying emotions, self-soothing, and expressing feelings in healthy ways through play.
  • Plans For Continued Treatment: Client will continue with weekly play therapy sessions for the next 3 months. Parents will participate in monthly coaching sessions.
  • Coordination Of Care: No additional providers are involved in treatment currently. Will coordinate with school counselor if needed.