Client Name: [text name="variable_91" default="sample text"] Date of Service: [text name="variable_1" default="sample text"] Session #: [select name="variable_23" value="Initial|Discharge|"] Session Start/Stop Times: [text name="variable_111" default="sample text"] Session Format: [select name="variable_112" value="Remote Video|Remote Telephone|Remote Written"] Other Individuals Present: [select name="variable_25" value="Yes|No, Client Only|"] Consent on File for Other Individuals Present: [select name="variable_113" value="Yes|N/A|"] Referral Source: Better Help Address of Present Location: [text name="variable_114" default="sample text"] Telehealth Checklist (completed prior to commencement of session) [checkbox name="variable_1" value="Client is appropriate for teletherapy|Disclosed therapist’s name, location, license number, and contact information|Verified the identification of the client receiving teletherapy services|Obtained oral and written acknowledgment from the client|Established/reviewed safety protocols to be used in case of an emergency|Identified all individuals present at each location and confirmed permission to hear client’s health information|Confirmed best practices for teletherapy to ensure both client confidentiality and the security of the communication medium|Obtained/confirmed an alternative method of contacting the client in case of technological failure"] Client arrived [select name="variable_115" value="on time|late|"] for scheduled [select name="variable_116" value="Initial|Ongoing|Discharge|"] individual therapy session. Client provided acknowledgment and consent to engage in a remote [select name="variable_117" value="telephone|video|written|"] session". Client is a [text name="variable_30" default="sample text"]year old, [select name="variable_32" value="single|married|divorced"] [select name="variable_31" value="male|female"] currently living in the state of [text name="variable_118" default="sample text"]. [select name="variable_119" value="He|She"]reported that [select name="variable_120" value="he|she"] is seeking mental health therapy at this time [text name="variable_121" default="sample text"]. Assessment of Status & Functioning [select name="variable_5" value="100-91 Superior functioning in a wide range of activities|90-81 Absent or minimal symptoms|80-71 Symptoms are transient and expectable reactions to psychosocial stressors or slight impairment in functioning|70-61 Mild symptoms or impairments in functioning|60-51 Moderate symptoms or impairments in functioning|50-41 Serious symptoms or impairment in functioning|"] Client is [checkbox name="variable_123" value="Oriented to person, place, time, and event|Not oriented to person, place, time, and event|Not oriented to place, time, or event|Not orientated to time and event|Not oriented to event|Obtunded|Disoriented"] Client maintained [checkbox name="variable_1000" value="appropriate posture and mannerisms|good eye contact|fair eye contact|avoidant eye contact|shifting eye contact|periods of staring in the distance|and showed signs of psychomotor agitation|and showed signs of psychomotor retardation"] Client exhibited [select name="variable_125" value="symptoms of mild psychological distress|moderate psychological distress|acute psychological distress|no apparent symptoms of psychological distress"] There is [select name="variable_1001" value="no apparent motor function impairment observed at this time|motor function impairment observed at this time that may be consistent with"] [checkbox name="variable_40" value="akathisia|catatonia|dystonia|tremor"] Client appeared [checkbox name="variable_126" value="stated chronological age|older than stated chronological age|younger than chronological age"] and was [checkbox name="variable_127" value="appropriately dressed and groomed|underdressed|overdressed|disheveled in dress and grooming|bizarre in dress and grooming"] with [checkbox name="variable_44" value="no visible indication of impaired hygiene|visible indication of impaired hygiene"] Client appears [checkbox name="variable_45" value="average weight|overweight|obese|underweight"] Client's attitude is described as [checkbox name="variable_46" value="antagonistic|hostile|silent|maintaining inappropriate boundaries|maintaining appropriate boundaries|seductive|playful|ingratiating|evasive|guarded|defensive|evasive|suspicious|attentive|charming|childish|communicative|controlling|critical|distant|eager to please|engaged|entitled|flattering|interactive|sullen|manipulative|contemptuous|demanding|withdrawn"] Client's attitude [select name="variable_47" value="remained stable throughout the duration of the session|fluctuated throughout the duration of the session"] and was [select name="variable_48" value="congruent to the content|incongruent to the content"] Client displayed [checkbox name="variable_128" value="a full range of affect with normal intensity|a blunted affect|a broad affect|a flat affect|a constricted affect|a restricted affect"] that appeared [checkbox name="variable_63" value="appropriate to context|inappropropriate to context|congruent to mood|incongruent to mood"] Client is described as [checkbox name="variable_60" value= "agitated|angry|animated|anxious|apathetic|anhedonic|aysphoric|detached|elated|euphoric|euthymic|even|expansive|hyper-energized|indifferent|irritable|labile|restricted|sad"] that [select name="variable_129" value="remained stable throughout the duration of the session|fluctuated throughout the duration of the session"] and appeared [checkbox name="variable_70" value="appropriate to context|inappropropriate to context"] Client's speech was [checkbox name="variable_71" value="clear|coherent|logical|normal rate and flow|normal volume|normal rhythm|normal content|loud|soft|rapid|slowed|pressured|inaudible|incoherent"] Remarkable for [checkbox name="variable_76" value="accent/dialect|clanging|echolalia|latency|neologism|perseveration|paucity|spontaneity|stuttering|slurring|mumbling|lisping|long pauses|responding only to questions|being scant|being mute|being verbose|overtalking|being repetitive"] Thought content [select name="variable_90" value="is within normal limits and|and perception are remarkable for"] [checkbox name="variable_80" value="perception is intact|thought withdrawal|thought insertion|paranoia|thought broadcast|grandiose delusions|somatic delusions|delusional guilt|nihilistic delusions|ideas of reference|ideas of inference|magical thinking|illusions|hallucinations|denationalization|derealization/depersonalization"] Client displayed features consistent with [checkbox name="variable_91" value="obsession|compulsion|preoccupation|rumination|phobia"] Thought form and flow is [checkbox name="variable_130" value="logical|linear|goal-directed|relevant|not logical|not relevant|not linear|not goal-directed|past orientated|scattered|impoverished|positive for racing thoughts|circumstantial|positive for perservations|positive for flight of ideas|illogical|incoherent|positive for neologism|distractable|tangential|positive for overvalued ideas|excited|positive for poverty of thought|positive for word salad|positive for clang associations|positive for slowed reaction|positive for rapid reaction|doubting|indecisive|positive for blocking|spontaneous|pressured|fragmented|positive for loose associations"] Client's cognition appears [checkbox name="variable_132" value="within normal limits|is grossly intact|below average|above average|average|alert|drowsy|lethargic"] Client displayed [checkbox name="variable_138" value="no apparent memory impairment|apparent impaired memory|no apparent concentration impairment|apparent impaired concentration|no apparent attention impairment|apparent impairment in attention|normal ability to abstract|difficulty with abstract thought|inability for abstract thought"] Client has [checkbox name="variable_133" value="full awareness/understanding of situation|partial awareness/understanding of situation|poor to no awareness/understanding of situation"] and judgment appears [select value="good|fair|poor"]. Client appears to present a low risk for self-harm and harm to others at this time. Client was assessed for safety using the Columbia. Client scored. Client denied any current thoughts of self-harm or thoughts to harm others. Client was open and willing to complete a safety plan as part of a remote therapy safety protocol and identified supportive resources available if current risk level to self or others changes in severity. Client has resources available if his/her level of risk should change in severity and confirmed that he/she will notify therapist if level of risk should change in severity and that he/she will contact the crisis hotline, contact his/her emergency contact, and contact emergency services or go to the local emergency room in the event of a crisis. Additional information: [textarea cols="80" rows="3" default= "No additional information."] Problem Areas [checklist name="variable_1" value="Abandonment|Abuse|Academic Concerns|Addictions and Compulsions|Adjusting to Change/Life Transitions|Aggression and Violence|Aging and Geriatric Issues|Anger|Family Problems|Family of Origin Issues|Fatigue|Fear|Forgiveness|Financial Issues|Gender Identity|Guilt|Grief, Lossm Bereavement|Panic|Paranoia|Parenting|Phobias|Non-traditional Relationships|Post-partum Depression|Post-Traumatic Stress|Power|Pregnancy and Childbirth|Prejudice and Discrimination|Mood Disorder|Anxiety Disorder|Body Image|Breakup|Bullying|Rejection|Religious Issues|Relationships and Marriage|Physical Health|Chronic Illness and Disability|Chronic Pain|Co-Dependency|Impulsivity|Inadequacy|Infidelity|Isolation|Loneliness|Self-Care|Self-Doubt|Self-Esteem|Self-Love|Self-Compassion|Commitment Issues|Communication|Control|Obsessions|Compulsions|Jealousy|Shame|Sexuality|Sleep|Phobia|Social Anxiety|Spirituality|Stress|Dependency|Depersonalization|Dissociation|Sexual Orientation|Trust Issues|Eating and Food Issues|Body Image|Feeling Overwhelmed|Emptiness|Divorce|Separation|New Family|Neglect|Worry|Rumination|Preoccupation|Values|COVID|Support|Emotionally Overhwelmed|Tired|Acadmic Issues|Employment Issues|Career Issues|Hopeless"] The main themes of today's session included [textarea name="variable_1" default="sample text"] Therapeutic interventions utilized to address the main themes of today's session included[checkbox name="variable_134" value="Interpreting mental and emotional processes|Probing for recurring patterns in the client's subconscious mind|Guiding the client through the examination of unresolved conflicts and significant events in the client's past|Identifying themes in the client's emotions, thoughts, and beliefs|Assisting client to gain insight about the client's current self|Attempts to clarify what is consciously going on in the client's mind|Supporting the client to bring into awareness nonverbal aspects of the client's behavior|Exploring the client's use of language|Encouraging introspection about childhood experiences as influences in their current behaviors|Exploring the client's representation of self and other|Analyzing conflicts between motivational and affective states|Highlighting the client’s emotional and interpersonal patterns|Providing interactional experiences that serve corrective developmental purposes|Observation and clarification of difficult or contradictory thoughts and feelings|Joint exploration of unconscious meanings and motivations|Exploration of concerns and issues in the client’s world|Exploration of the relational dynamics occurring between therapist and client|Mirroring the client's emotional responses|Restructuring and reframing|Guided discovery|Relaxation and stress reduction techniques|Creating actionable goals that promote problem-solving|Assisting client to identify undesirable or inappropriate behaviors|Validating positive behaviors|Supporting the client to bring into awareness nonverbal aspects of the client's behavior|Exploring the client's use of language|Encouraging introspection about childhood experiences as influences in their current behaviors|Exploring the client's representation of self and other|Analyzing conflicts between motivational and affective states|Highlighting the client’s emotional and interpersonal patterns|Providing interactional experiences that serve corrective developmental purposes|Observation and clarification of difficult or contradictory thoughts and feelings|Joint exploration of unconscious meanings and motivations|Exploration of concerns and issues in the client’s world|Exploration of the relational dynamics occurring between therapist and client|Mirroring the client's emotional responses"] [textarea name="variable_1" default="sample text"] Client was an active and willing participant in his/her treatment. Client was open and responsive to the interventions and appeared engaged and optimistic during the therapuetic process. Client acknowledged that the interventions were supportive in addressing his/her problem areas and goals for treatment and shared that [textarea name="variable_1" default="sample text"]. Assessment of Progress Client appears motivated to achieve treatment goals as evidenced by his/her active participation in the treatment session and the completion of homework assignments, weekly exercises, and reflective journaling in between sessions. Client reported that he/she continued to process material addressed in the previous week's session and utilized interventions in resopnse to identified problem areas. [textarea name="variable_1" default="sample text"] Plan Client scheduled his/her next individual therapy session for [text name="variable_1" default="sample text"]. Client is encouraged to continue to complete homework assignments, weekly exercises, and reflective journaling in between sessions. Client will [textarea name="variable_1" default="sample text"] Diagnosis [textarea name="variable_1" default="sample text"]
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