ࡱ> q` bjbjqPqP '::SXllll4#4#4#8l#<#>`$$$$$ ) ) )4444K+54_94=$r?hA=K+s( )K+K+=ll$$=---K+jl8$$4-K+4--:r0,0$$ F]l4#+0 "1=0>0.B,B0B0L )Zg)@-)4)p ) ) )==-^ ) ) )>K+K+K+K+d4#4#llllll  SHAPE \* MERGEFORMAT  SESSION SUMMARY: PLAY THERAPY Date__/___/__ Session #__ Page 1 of 2 --- continued on back --- Signature required Child/Age___________________________/________ Student-Counselor______________________________ Theory _______________ Specific Interventions Used (if any) ________________________________________Supervisor Name_____________________________ I. SUBJECTIVE: Underline all feelings, including capitalized words, expressed directly or through a toy (write toy above feeling). Circle predominate feeling(s). HAPPY: relieved, satisfied, pleased, delighted, excited, surprised, silly CONFIDENT: proud, strong, powerful, determined, free SAD: disappointed, hopeless, pessimistic, discouraged, lonely HESITANT: timid, confused, nervous, embarrassed, ashamed ANGRY: impatient, annoyed, frustrated, mad, mean, jealous CURIOUS: interested, focused AFRAID: vulnerable, helpless, distrustful, anxious, fearful, scared, terrified FLAT: contained, ambiguous, restricted  II. OBJECTIVE: A. TOYS/PLAY BEHAVIOR Circle specific toys used (not category), give brief description of play. In blank, indicate meaningful/sustained play with "(", indicate play disruption as "PD", and indicate therapist initiated activity as "TH" (Use your own code system for info important to you - ex:1st time or discontinued use of toy). ___hammer/log/woodworking ___sandbox/water/sink ___theater/puppets ___kitchen/cooking/food ___easel/paint/chalkboard ___bean bag/pillows/sheet/blanket ___bop bag/foam bats/etc ___dress up: clothes/fabrics/shoes/jewelry/hats/masks/wand ___crafts/clay/markers/etc. ___doll house/doll family/bottle/pacifier/baby ___cash register/money/phone ___camera/flashlight ___medical kit/bandages ___musical instruments ___games/bowling/ring toss/balls/etc. ___cars/trucks/bus/emergency vehicles/planes/boats/riding car ___animals: domestic/zoo/alligator/dinosaurs/shark/snake ___soldiers/guns/knife/sword/handcuffs/rope ___constructive toys/blocks/barricade ___sandtray/miniatures B. SIGNIFICANT VERBALIZATION: CH=Child initiated TH=Therapist initiated _________________________________________/_______ Developed by Bratton & Homeyer (updated 7/2002) Student Counselor Signature Date Texas State University- Play Therapy Session Summary Page 2 of 2 C. LIMITS SET: Write limits set beside the RATIONALE (ex: threw sand on floor) & in the blank, indicate # of times limit set. If consequence and/or ultimate limit was set in response to broken limit, describe process. ___Protect Child (Physical & Emotional Safety): ___Protect Therapist and/or Maintain Therapist Acceptance/Relationship: ___Protect Room/Toys: ___Structuring: ___Reality Testing:  III. ASSESSMENT: General Impressions/Clinical Understanding A. DYNAMICS OF SESSION: Rate Childs Overall Play Behavior Childs Activity Level (low) 1 2 3 45 67 8 9 10Childs Activity Level (high)Intensity of Play (low) 1 2 3 45 67 8 9 10Intensity of Play (high)Inclusion of therapist (low) 1 2 3 45 67 8 9 10Inclusion of Therapist (high)Destructive 1 2 3 45 67 8 9 10ConstructiveMessy/Chaotic/Disorganized 1 2 3 45 67 8 9 10Neat/Orderly B. PLAY THEMES: Underline all that apply, including capitalized words, & describe how theme was played out (toys used, etc). Circle predominate theme(s). EXPLORATORY: (not a true play theme - rather the way child gets comfortable & familiar with playroom) RELATIONSHIP: connecting/trust/approval seeking/manipulative/collaborative/testing limits POWER/CONTROL: HELPLESS/INADEQUATE: AGGRESSION/REVENGE: SAFETY/SECURITY: MASTERY: deconstructing/constructive/competency/integration/resolution NURTURING: self-care/reparative/healing DEATH/LOSS/GRIEVING: SEXUALIZED: OTHER: C. OVERALL, CHILD'S BEHAVIOR / AFFECT WAS: MALADAPTIVE / NON-COPINGADAPTIVE / COPINGSad/depressed/angry/fearful 1 2 3 4 5 6 7 89 10Content/satisfied (Appropriate Affect)Anxious/insecure 1 2 3 4 5 6 7 89 10Confident/secureDependent/clingy/needy 1 2 3 4 5 6 7 89 10Autonomous/IndependentImmature/regressed/hypermature 1 2 3 4 5 6 7 89 10Age appropriateLow frustration tolerance 1 2 3 4 5 6 7 89 10High frustration toleranceExternal locus of control 1 2 3 4 5 6 7 89 10Internal locus of control (self-controlled)Impulsive/easily distracted 1 2 3 4 5 6 7 89 10Purposeful/focusedInhibited/Constricted 1 2 3 4 5 6 7 89 10Creative/Expressive/Spontaneous/FreeIsolated/Detached 1 2 3 4 5 6 7 89 10Connected/Sense of Belonging D. CONCEPTUALIZATION OF CLIENT AND CLIENT'S PROGRESS BASED ON THEORETICAL ORIENTATION: IV. 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