B.I.R.P. Note Example

The following progress note is from a 3 hour intensive in-home session on 6/29/23 from 9AM to 12PM in the B.I.R.P. format we use at CAVA for all progress notes. Names have been removed in order to protect client confidentiality but he is a nearly 14 year old boy who struggles with respectful communication with adults, is diagnosed with depression, and has recently been expressing an increased frequency of mood swings.

Treatment Goals: 

The client will learn strategies to manage his depressive symptoms through the development of coping skills, self soothing techniques, and affect regulation strategies. 

Objective: The client will identify and name 3 triggers that lead to outbursts and increase his ability to communicate about them. 

The family will work towards rebuilding trust and care through healthy communication and reestablishing the parental hierarchy.

B = Behaviors: 

Client presented as tired and at the beginning of the session was just waking up. Client held his head in his hands, avoided eye contact, and tried to look at his phone instead of engaging in the session. Client faked going to sleep to try and get out of session and actively ignored family members when they spoke to him. 

I = Interventions:

Counselor joined with the client through completion of morning activities of daily life. Counselor created a safe space for the session to take place in. Counselor asked questions about the client’s sleeping patterns. Counselor explored poor sleep habits with the client and connected them to negative moods and lack of energy. Counselor asked the client why he was refusing to participate in services. Counselor held space for the client to share his feelings. Counselor challenged the client for raising his voice at his grandmother when she asked him a question. Counselor explored different ways that the client could communicate he does not want to be talked to respectfully. 

R = Responses:

Client was noticeably tired and reported that he was awake until around 3am the prior night. Client stated he was playing Xbox and that he usually goes to bed very late. Client stated that he was usually the most “cranky” in the mornings and that he liked to be left alone when he was tired. Client reported to understand that his poor mood and energy levels could be related to lack of sleep but stated that he “doesn’t really care.” Client stopped responding to questions and began texting, and when prompted to put his phone away, he did but then shut his eyes and refused to respond. When the client’s grandmother entered the room to bring the client a drink, he refused to speak or make eye contact with her, which she questioned. When repeatedly questioned, the client raised his voice and stated, “Can’t you tell I want to be left the hell alone?” Client stated he did not like to raise his voice but that “if I say what I really want to say I’ll just hurt someone’s feelings.” Client stated he knew that he could speak nicer, but “If she (client grandmother) is going to come at me, I’m going to come at her.” Client refused to share what he was feeling at that moment and sat in near silence for over an hour and a half. 

P = Plan:

The counselor will continue to meet with the client to understand the relationship dynamic with the client’s grandmother and work on processing his emotional outbursts. 

——————————————————————————————————————————-

S.O.A.P Note Example

The following case took place over the phone on June 22nd, 2022 while performing a routine referral assessment with a client’s guardian in order to gather information on their child’s presenting problem(s), their trauma history, as well as gather insurance information. Names have been changed in order to protect the client’s privacy.

1. Subjective Data: Lilly is a 6 year old girl who has made an admission of sexual assault to her mother. Lilly stated that while on visitation at her biological father’s house, a boy of 11-12 years of age was sleeping in the same bed as her and touching her genitals and humping her at night. According to the client’s mother, there are up to 5 total children in the biological father’s house at any time and at least 10 adults who come and go and she is worried about her child’s physical safety and mental wellbeing. Since beginning visitation at her father’s house at the beginning of the month, Lilly has begun wetting herself, becoming defensive about her mother helping her in the bathroom, and has nightmares about “a boy touching her.” She has been acting out sexually by peeping on others and sticking her fingers in her genitals at random. She has also been talking to herself when she is alone, recounting what has happened to her while at her father’s house. These symptoms began shortly after visitation began, and have persisted for approximately the last month. The client’s mother has been in contact with the local police department and gave a statement to a detective, but was not sure if a report had been filed with Child Protective Services and wanted to do everything she could to stop visitation as soon as possible. 

2. Objective Data: The client’s mother was noticeably distressed at the beginning of the call, heard in her tone, elevated volume, and changes in the speed of her speech. She seemed a bit annoyed at the onset of the call with the process of acquiring demographic information for herself and her daughter, but complied with all the required data to get into the waitlist for services, with the exception of her insurance information. The mother became much more quiet once she began discussing her daughter’s trauma history and the reasons for wanting to get into services. Several times she took long pauses, sniffled or deeply sighed, and expressed that she felt she was at a loss for what to do anymore, and felt trapped by the court’s order for visitation rights. 

3. Assessment: The intern believes from the client’s disclosure to her mother and the symptoms the client has exhibited since beginning visitation at her biological father’s house that she has been traumatized via sexual assault. The client has begun dissociating and talking to herself as a means of talking through her trauma and processing it. The client has begun acting out sexually, has regular nightmares, and is withdrawn. While the intern did not relay any assessment to the client’s mother, as it would be out of the bounds of their training, these symptoms point towards a possible diagnosis of Post-Traumatic Stress Disorder as described in the DSM-5 (2013).

4. Plan: The intern will consult with their supervisor to discuss the need for immediate services with this client, as well as arranging to fulfill the intern’s duty as a mandated reporter and making a report of sexual abuse to Child Protective Services. This case necessitated a CPS report as there was an admission of sexual abuse to a child. As this child has experienced a traumatic event within the last six months they qualify for ChildSavers’ short term services which work on coping mechanisms to process this trauma, before moving into long-term outpatient services. It will be important for the client to enroll in services as soon as possible in order to stop the negative coping mechanisms she has exhibited since the first incident. The client’s mother only needs to provide insurance information for the client to be put on the waitlist for services.