Initial Session

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"]
Client Name:
Date of Service:
Session #:
Session Start/Stop Times:
Session Format:
Other Individuals Present:
Consent on File for Other Individuals Present:
Referral Source: Better Help
Address of Present Location:

Telehealth Checklist (completed prior to commencement of session)

Client arrived for scheduled individual therapy session. Client provided acknowledgment and consent to engage in a remote session".

Client is a year old, currently living in the state of . reported that is seeking mental health therapy at this time .

Assessment of Status & Functioning

Client is Client maintained Client exhibited There is
Client appeared and was with Client appears Client's attitude is described as Client's attitude and was Client displayed that appeared Client is described as that and appeared Client's speech was Remarkable for Thought content
Client displayed features consistent with Thought form and flow is Client's cognition appears Client displayed Client has and judgment appears .

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:

Problem Areas


The main themes of today's session included


Therapeutic interventions utilized to address the main themes of today's session included


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 .

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.


Plan
Client scheduled his/her next individual therapy session for
. Client is encouraged to continue to complete homework assignments, weekly exercises, and reflective journaling in between sessions. Client will


Diagnosis

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.74, 57 form elements, 437 boilerplate words, 8 text boxes, 7 text areas, 22 checkboxes, 1 check lists, 19 drop downs, 367 total clicks
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