SOAP

SUBJECTIVE
Client expressed the following about the problem, "[text name="quote" default=""]."
The following concerns and/or updates since last session were addressed:        [textarea name="updates" default=""]

Client reports most prevalent symptoms since last session as: 
[checkbox name="Symptoms" value="Depressed Mood|Sadness|Anhedonia|Tearful or crying spells|Fatigue/Low energy|Negative Cognitions|Restlessness|Physical Retardation|Low motivation|Hyperactivity|Inattention|Difficulty with organization|Difficulty with task initiation|Difficulty persisting on challenging or tedious task|Difficulty handling transitions|Poor academic performance|Poor work performance|Isolating behaviors|Loneliness|Poor self-esteem|Increased energy|Euphoria|Risk taking behaviors or urges|Excessive self-confidence/self-esteem|Racing thoughts|Uncontrolled Worry/Anxiety|Anxiety of social situations|Fear of negative evaluation by others|Panic/Abrupt surge of intense fear|Worry about having future panic attacks|Difficulty with concentration|Muscle tension|Psychosomatic symptoms|Panic attack|Hopelessness|Feelings of worthlessness/inappropriate guilt|Intrusive thoughts|Flashbacks|Dissociation/Depersonalization/Derealization|Avoidance of thoughts/memories|Impulsivity|Obsessions|Compulsions|Phobia|Substance abuse|Negative body image|Binging/overeating|Restricting|Purging behaviors|Weight changes|Hypervigilance/Easily startled|Grief|Low self-confidence|Interpersonal conflicts|Irritability|Worry about "][checkbox name="Worry" value="work/school|finances|health|relationships"][text  default=""]
Sleep: [checkbox name="sleep" value="Within normal limits|Change    in    sleep    cycle|Difficulty falling asleep|Difficulty staying asleep|Excessive sleep|Nightmares"]
Appetite: [checkbox name="Appetite" value="Within normal limits|Increased appetite|Decreased appetite"]

Focus/themes of session for today was: 
[checkbox name="Mood0" memo="Mood Management" value=""][checkbox name="ADHD0" memo="ADHD" value=""][checkbox name="Interpersonal0" memo="Interpersonal Problems" value=""][checkbox name="Relationship" memo="Relationship Distress" value=""][checkbox name="Attachment" memo="Attachment Issues" value=""][checkbox name="Gender" memo="Gender/Sexuality" value=""][checkbox name="Trauma0" memo="Trauma" value=""][checkbox name="Behavioral0" memo="Behavioral Health Issues" value=""][checkbox name="Grief0" memo="Grief/Loss" value=""][checkbox name="Adjustment" memo="Adjustment Disorder" value=""][checkbox name="Substances" memo="Substance Use Issues" value=""][checkbox name="Medical" memo="Medical/Health Issues" value=""][checkbox name="Stressors0" memo="Stressors" value=""][checkbox name="Body" memo="Body Image/ED" value=""][checkbox name="Other0" memo="Other Topics" value=""][conditional field="Mood0" condition="(Mood0).is('')"] --MOOD MANAGEMENT-- [checkbox value="Current symptoms/functioning|Management of symptoms|Anger|Anxiety|Depression|Distress intolerance|Emotion dysregulation|Negative cognitions"] [/conditional][conditional field="ADHD0" condition="(ADHD0).is('')"] --ADHD-- [checkbox value="ADHD symptoms|Attention management|ADHD medications|Management of executive dysfunction"] [/conditional][conditional field="Interpersonal0" condition="(Interpersonal0).is('')"] --INTERPERSONAL PROBLEMS-- [checkbox value="Interpersonal conflict|Conflict with friend(s)|Conflict with family|Conflict with extended family|Conflict with family of origin|Conflict within nuclear family|Conflict with spouse/significant other|Conflict with coworker(s)|Conflict with peer(s)|Communication issues|Boundary issues|Difficulty saying no to others|Passive behaviors|Aggressive behaviors|Passive-Aggressive behaviors|Co-dependent behaviors"] [/conditional][conditional field="Relationship" condition="(Relationship).is('')"] --RELATIONSHIP DISTRESS-- [checkbox value="Relationship dissatisfaction|Conflict/argument|Intimacy concerns|Infidelity concerns|Trust concerns|Divorce Concerns|Breakup/acute relationship concerns|Abuse/IPV|Relationship trauma"] [/conditional][conditional field="Attachment" condition="(Attachment).is('')"] --ATTACHMENT ISSUES-- [checkbox value="Anxious/Preoccupied Attachment|Fear of abandonment|Clinging behaviors|Prioritizing partner over self|Seeking validation|Avoidant/Dismissive Attachment|Distrust of others|Fear of intimacy|Excessive need for self-reliance|Rigid boundaries|Disorganized/Fearful-Avoidant Attachment"] [/conditional][conditional field="Gender" condition="(Gender).is('')"] --GENDER/SEXUALITY-- [checkbox value="Gender Identity distress|Sexual Orientation distress|Coming out process|Reactions from friends/family/others"] [/conditional][conditional field="Trauma0" condition="(Trauma0).is('')"] --TRAUMA-- [checkbox value="Past trauma event|Recent trauma event|Relationship trauma|Childhood trauma|Sexual trauma event|Neglect"] [/conditional][conditional field="Behavioral0" condition="(Behavioral0).is('')"] --BEHAVIORAL HEALTH ISSUES-- [checkbox value="Self-care|Sleep difficulty/concerns|Nutrition/Eating habits|Physical activity/exercise"] [/conditional][conditional field="Grief0" condition="(Grief0).is('')"] --GRIEF/LOSS-- [checkbox value="Death of family member|Death of friend|Grief reactions|Processing past regrets|Processing grief|Processing a death/loss"] [/conditional][conditional field="Adjustment" condition="(Adjustment).is('')"] --ADJUSTMENT ISSUES-- [checkbox value="Adjustment to stressor(s)|Adjustment to workplace changes|Adjustment to job loss/change|Adjustment to relationship changes|Adjustment to family life changes|Adjustment to a developmental event"] [/conditional][conditional field="Substances" condition="(Substances).is('')"] --SUBSTANCE USE ISSUES-- [checkbox value="Alcohol use concerns|Cannabis use concerns|Nicotine use concerns|Opioid use concerns|Benzodiazepines use concerns|Amphetamine use concerns|Relapse prevention"] [/conditional][conditional field="Medical" condition="(Medical).is('')"] --MEDICAL/HEALTH CONCERNS-- [checkbox value="Medical/health concerns|Medication concerns/side effects|New diagnosis|Physical pain/injury|Healthcare concerns"] [/conditional][conditional field="Stressors0" condition="(Stressors0).is('')"] --STRESSORS-- [checkbox value="Life stressors|Coping mechanisms|Family dysfunction|Work problems|School problems|Bullying|Work-related stress|Negative work environment|Difficulty with work/life balance|Financial issues|Legal issues|Housing issues|Relationship issues|Friend issues"] [/conditional][conditional field="Body" condition="(Body).is('')"] --BODY IMAGE/EATING DISORDER ISSUES-- [checkbox value="Negative body cognitions|Body dysmorphia|Eating disordered behaviors"] [/conditional][conditional field="Other0" condition="(Other0).is('')"] --OTHER TOPICS-- [checkbox value="Religious/spiritual concerns|Homework/assignment follow up|Goals/treatment plan review"] [/conditional]

Medication compliance: [checkbox name="compliance" value="Compliant|Irregular|Stopped"]
Changes in medication: [text name="changes" default="None noted"]
Medications: [text name="meds" default=""]
Medication provider(s): [text name="provider" default=""]

OBJECTIVE
Orientation: [checkbox name="Orientation" value="Alert and Oriented x4|Impairment"] 
Appearance: [checkbox name="Appearance" value="Neat/clean|Unkempt/disheveled|Poor hygiene|Inappropriate dress"]
Reported Mood: [checkbox name="Mood1" value="Euthymic|Depressed|Anxious|Irritable|Ephoric"]
Affect: [checkbox name="Affect" value="Full range|Expansive|Euthymic|Constricted|Blunted|Flat|Labile|Congruent to mood/thoughts|Incongruent to mood/thoughts"]
Behavior: [checkbox name="Behavior" value="Good eye contact|Poor eye contact|Fidgety|Physical retardation|Slouched|Normal posture|Erect posture|Tics"]
Speech: [checkbox name="Speech" value="Within normal limits|Loud|Soft|Fast|Slow|Pressured|Stutter|Tic"]
Thought process: [checkbox name="Thought" value="Within normal limits|Flight of ideas|Tangential|Circumstantial|Word salad|Thought blocking|Poverty|Racing|Looseness of association"]
Insight: [checkbox name="Insight" value="Excellent|Good|Fair|Poor"]
Judgement: [checkbox name="Judgement" value="Excellent|Good|Fair|Poor"]
Thought Content: [checkbox name="Hallucinations" value="None reported|Auditory hallucinations|Visual hallucinations|Tactile hallucinations|Delusions|Dissociation|Reported by client during week|Observed by therapist during session"]

ASSESSMENT
Suicidality/Homicidality: [checkbox name="SI_HI" value="None reported|SI|HI|Active|Passive"] Intensity of urges [select name="SI_intense" value="0|1|2|3|4|5|6|7|8|9|10"]/10
Self-harm: [checkbox name="SIB" value="None reported|Urges|Actions|Active|Passive"] Intensity of urges [select name="SIB_intense" value="0|1|2|3|4|5|6|7|8|9|10"]/10
Risk factors: [checkbox name="Risk" value="None noted|History of SI|History of HI|History of self-harm|Substance use"]

Client reports symptoms consistent with diagnosis of: [checkbox name="Diagnosis" value="Major Depression Disorder|Persistent Depressive Disorder|Bipolar Disorder|Generalized Anxiety Disorder|Social Phobia|Obsessive Compulsive Disorder|Attention Deficit Hyperactivity Disorder|Autism Spectrum Disorder|Posttraumatic Stress Disorder|Borderline Personality Disorder|Eating Disorder|Schizoaffective Disorder|Panic Disorder|Adjustment Disorder|Gender Identity Disorder"] [text name="other" default=""]

Client displayed the following strengths and capabilities during the session:
[checkbox name="strengths" value="motivation to progress in treatment|utilization of positive coping techniques|ability to express emotions|ability to receive feedback from therapist|awareness of emotions|awareness and honesty around negative coping techniques|ability to tolerate painful feelings|openness to trying new, positive behaviors|having compassion for self"]

INTERVENTIONS:
In session interventions provided: [checkbox name="MOOD" memo="MOOD DISORDER" value=""][checkbox name="GENERAL" memo="GENERAL" value=""][checkbox name="INTERPERSONAL" memo="INTERPERSONAL" value=""][checkbox name="BEHAVIORAL" memo="BEHAVIORAL HEALTH" value=""][checkbox name="CBT" memo="CBT THERAPY" value=""][checkbox name="DBT2" memo="DBT THERAPY" value=""][checkbox name="ADHD1" memo="ADHD" value=""][checkbox name="Body2" memo="BODY IMAGE" value=""][checkbox name="COUPLES" memo="COUPLES/FAMILY" value=""][checkbox name="TRAUMA2" memo="TRAUMA/GRIEF" value=""][checkbox name="STRESS2" memo="STRESS MANAGEMENT" value=""][checkbox name="MOTIVATION" memo="MOTIVATIONAL INTERVIEWING" value=""][conditional field="MOOD" condition="(MOOD).is('')"] -MOOD DISORDER INTERVENTION- [checkbox value= "Active listening and feedback|Validated and normalized thoughts/emotions|Supportive reflection|Open-ended questions|Socratic questioning|Self-disclosure|Clarification|Reframing|Praise and encouragement|Reassurance|Rapport building"][/conditional][conditional field="GENERAL" condition="(GENERAL).is('')"] -GENERAL INTERVENTIONS [checkbox value= "Problem-solving|Role playing|Identifying/labeling emotions|Processing thoughts and feelings|Identifying negative coping|Identifying defense mechanisms|Identifying strengths and support system|Psychoeducation|Identifying barriers to treatment|Reviewing homework|Providing resources/literature|Reviewing treatment plan|Goal setting|Administration of clinical assessments|Reviewing treatment frequency|Referral to provider"][/conditional][conditional field="INTERPERSONAL" condition="(INTERPERSONAL).is('')"] -INTERPERSONAL INTERVENTIONS- [checkbox value="Exploration and education of communication skills to address interpersonal concerns|Education/practice of assertive communication skills|Education of 'I feel' statements|Exploration of interpersonal patterns|Education of boundaries|Identifying and discussing boundary setting|Assisting client in practicing communication|Exploration of communication patterns"][/conditional][conditional field="BEHAVIORAL" condition="(BEHAVIORAL).is('')"] -BEHAVIORAL HEALTH INTERVENTIONS- [checkbox value= "Explored self-care strategies|Sleep hygiene interventions|Behavioral activation|Identifying ways improve completion of ADL's|Identifying avoidance/denial patterns|SMART goals|Identifying positive affirmations|Identifying/Reviewing positive coping skills|Identifying hobbies|Identifying values/morals/beliefs|Discussing benefits of medication"][/conditional][conditional field="CBT" condition="(CBT).is('')"] -CBT THERAPY- [checkbox value="Education of CBT model|Identifying cognitive distortions|Cognitive challenging|Cognitive restructuring|Identification of distorted automatic thoughts|Identifying negative thinking patterns using examples from client's life|Reviewing 'feeling's wheel'|Developing alternate thoughts and beliefs|Exploring how thoughts/beliefs influence mood and behaviors"][/conditional][conditional field="DBT2" condition="(DBT2).is('')"] -DBT THERAPY- [checkbox value="Emotion Regulation skills|Mindfulness skills|Distress Tolerance skills|Interpersonal Effectiveness skills|PLEASE|ACCEPTS|IMPROVE|TIPP|FAST|GIVE|DEARMAN|Who and What skills|Wise mind|Ride the Wave|Radical acceptance"] [/conditional] [conditional field="ADHD1" condition="(ADHD1).is('')"] -ADHD INTERVENTIONS- [checkbox value="Positive self-talk exercises|Time management skills|Organization skills|Prioritization skills|Executive dysfunction skill|Exploration of social constructs|Education/Resources about ADHD"] [/conditional][conditional field="Body2" condition="(Body2).is('')"] -BODY IMAGE INTERVENTIONS- [checkbox value="Identifying negative body thoughts|Identifying triggers|Challenging negative cognitions|Education of health/nutrition|Identifying negative cognitions' effects on life|Education of skills to prevent disordered eating|Challenging body image in mirror|Identifying origins of body image|Facing body image avoidance|Facing body image rituals|Identifying and challenging societal effects on body image"][/conditional][conditional field="COUPLES" condition="(COUPLES).is('')"] -COUPLES/FAMILY INTERVENTIONS- [checkbox value="Exploring of family dynamics|Facilitating healthy expression of feelings/concerns|Exploration of activities to enhance positive connection|Processing recent conflict or incident|Exploring patterns of closeness or distance in the relationship|Exploring communication styles/cycles|Observing and providing feedback on communication and interactions|Exploration of family of origin/dynamics|Explored solvable and perpetual problems"][/conditional][conditional field="TRAUMA2" condition="(TRAUMA2).is('')"] -TRAUMA & GRIEF/LOSS- [checkbox value="Exploring trauma and impact on client's life|Identifying patterns of avoidance|Identifying consequences of avoidance|Creation of trauma narrative|Psychoeducation on PTSD symptoms and treatment|Exploring trauma and abuse|Identifying triggers|Identifying coping skills|Exploration of strengths and support|Identifying and process grief/loss issues|Psychoeducation of grieving process"][/conditional][conditional field="STRESS2" condition="(STRESS2).is('')"] -STRESS MANAGEMENT- [checkbox value="Mindfulness activities|Grounding techniques|Progressive muscle relaxation|Deep breathing techniques|Guided Imagery|Distraction techniques|Identification of source of stress|Identifying and planning pleasurable activities"][/conditional][conditional field="MOTIVATION" condition="(MOTIVATION).is('')"] -MOTIVATIONAL INTERVIEWING- [checkbox value="Eliciting change talk|Eliciting alternative behaviors|Identifying pros/cons to change|Assessing readiness for change"][/conditional]

Client's observable reactions to interventions were: [checkbox name="reactions" value="Positive/Motivated|Engaged|Resistant|Hesitant|Negative"]

Treatment Progress: Client progress in achieving treatment goals is best assessed as [checkbox name="progress1" value="responding well to interventions|making some progress|slow/slight progress|fluctuating/intermittent progress|progress in one area of treatment|maintaining past gains|maintaining goal focus|increase in symptoms|decrease in symptoms|significant escalation of symptoms|minimal|improving|stable"] as evidenced by client self-report, observed behavior, and level of engagement.

[checkbox name="Testingcompleted" memo="Testing completed" value=""][conditional field="Testingcompleted" condition="(Testingcompleted).is('')"] Testing administered: [checkbox name="Tests" value="PHQ9|GAD7|PCL5|SPIN|OCI|"] [/conditional]

From the client’s report and therapist observation, client is experiencing impairment in the following areas:
Sense of meaning: [select name="functioning1" value="No|Mild|Moderate|Severe"] disruption to the client’s sense of meaning from life.
General wellbeing: [select name="functioning1" value="No|Mild|Moderate|Severe"] disruption to the client’s general sense of wellbeing and mental health in a way that the client can provide for self and dependent others.
Social/friendships: [select name="functioning2" value="No|Mild|Moderate|Severe"] disruption to the client’s ability to engage and/or derive satisfaction from social connections. 
Daily tasks: [select name="functioning3" value="No|Mild|Moderate|Severe"] disruption to the client’s ability to perform daily necessary tasks for life. 
Family: [select name="functioning4" value="No|Mild|Moderate|Severe"]  disruption to the client’s satisfaction and stability in family life and connection.
Work/Academic: [select name="functioning5" value="No|Mild|Moderate|Severe"] disruption to the client’s satisfaction or productivity in the client’s function at work/school.
Economic: [select name="functioning6" value="No|Mild|Moderate|Severe"] disruption to the client’s financial stability. 
Romantic relationships: [select name="functioning7" value="No|Mild|Moderate|Severe"] disruption to the client’s satisfaction from or ability to engage in romantic relationships.

PLAN
Changes in diagnosis or treatment plan: [text name="changes1" default="None noted"]

Frequency of sessions: [checkbox name="freq" value="Weekly individual therapy.|Bi-weekly individual therapy.|Return in 1-2 weeks.|Return in 1 month to assess functioning/progress.|Client will contact provider to schedule next session."]

Plan for next session is to review; [checkbox name="review" value="homework/outside assignments|recent stressors/emotional experiences|symptom intensity/frequency|goal achievement/outcomes|negative cognitions|mindfulness exercises|self-care|interpersonal relationships|ADL's|setting/maintaining boundaries|utilization of communication tools|utilization of coping strategies|eating/exercise habits|journaling"][text  default=""]

Homework: Ct agreed to     [textarea name="hw" default=""].


The service is medically necessary and appropriate for the treatment of the diagnosed condition to: [select name="necessity" value="Address symptoms/achieve symptomatic relief.|Improve functioning in one or more life domains.|Maintain progress/prevent decompensation.|Prevent higher level-of-care/avoid hospitalization."]