DAP MI Counseling Note

COUNSELING SESSION

Client's last session for counseling was [date name="variable_1" default="03/28/2019"] and last medical appointment was [date name="variable_1" default="03/28/2019"].

Client's last drug screen was [date name="UDS" default="03/28/2019"] and results appear as [checkbox name="results" value="normal.|abnormal."]

D: Client came to office to meet with this writer [checkbox name="reason" value="to engage for monthly counseling|at the request to see counselor"]. 

Writer invited client to initiate session by asking client to share their current status. Client reported to [textarea name="client report" default=""]. 
Writer demonstrated active listening skills, and when client finished reporting self-identified status, this writer used reflection, and clarified client's priorities and readiness. Using a collaborative approach to agenda map and client identified[text name="variable_1" default=""] as being an area which could be a primary focus for this session.  

Writer used open-ended questions to assist client in exploring the problem further, and this writer assessed client's understanding and previous barriers. Writer provided affirmations and built confidence through ask-tell-ask, where praise was given to support [comment memo="Praise: specify at least 1 positive event, attitude or strength of client identified"][text name="praise" default=""].

Client was asked to consider incremental changes to address their reported barriers. Client was able to identify [text name="variable_1" default=""] as a possibility. Writer used scaling questions to assess readiness and commitment, and worked collaboratively with client to develop a plan that includes adequate structure, accountability, benchmarks and rewards. Client and this writer developed homework for next session.

A: Client appears to be in [checklist name="variable_1" value="pre-contemplative|preparatory|action|maintenance"] stage of change in their recovery as evidenced by [comment memo="for pre-contemplative stage"][checklist name="pc" value="the client's report of no identified plans to change or address ongoing use in the next 6 months|expressed resistance to addressing ongoing substance use|use of sustain talk"][comment memo="for preparatory stage"][checklist name="prep" value="the client's report of no identified plans to change or address ongoing use in the next month|expressed but decrease in resistance to addressing ongoing substance use|ambivalence but slight improvement"][comment memo="for action stage"][checklist name="act" value="the client's report of identified plans to change or address ongoing use|expressed commitment to addressing substance use|use of change talk"][comment memo="for maintenance stage"][checklist name="main" value="the client's report of stability|expressed commitment to addressing relapse prevention|ongoing use of change talk"].
Client's progress in achieving treatment goals is best assessed as "[checkbox name="progress" value="minimal|resistant|progressing|improving|stable"]" as evidenced by client's reports, drug screen results, behavior and engagement.

P: Next session scheduled for [date name="variable_1" default="03/28/2019"]. Client reports commitment to [text name="v" default=""] prior to next session. This writer will remain available to offer resources if client needs support between session.

RESOURCES:
[checkbox name="RE" value="MI worksheet- Agenda Mapping.|MI worksheet- Exploring Pros and Cons|MI Worksheet- Change Plan|List of Community Resources for |Referral to |Phone Numbers for "][comment memo="Use text box to add specific resources or resources not listed"][textarea name="variable_1" default="sample text"].