all

able	
	
deescalate	
independently	
identify	
accessing	
services	
necessary	
secure	
placement	
accompanying	
in	
public	
model	
practice	
appropriate	
behavior	
affect	
rich	
flat	
restricted	
blunted	
etc	
agreed	
utilize	
peer	
support	
community	
resources	
or	
call	
	
if	
feels	
allergy	
medication	
food	
seasonal	
also	
reports	
frequent	
crying	
spells	
answered	
a	
couple	
questions	
“yes”	
“no”	
answer	
any	
change	
symptoms	
last	
year	
appeared	
pleased	
with	
goals	
decided	
upon	
expressed	
that	
could	
appears	
appetite	
appreciative	
of	
intervention	
drop	
are	
there	
safety	
issues	
need	
to	
be	
monitored?	
arrest	
history	
what	
arrested	
asking	
repeat	
while	
discussing	
suicidal	
homicidal	
assessed	
at	
low	
risk	
assessment	
regarding	
appropriateness	
least	
twice	
week	
fornex	
months	
during	
case	
management	
meetings	
plan	
attack	
addition	
explained	
post	
traumatic	
stress	
disorder	
ptsd	
attitude	
cooperative	
uncooperative	
evasive	
authorization	
form	
awareness	
illness	
began	
having	
great	
deal	
behalf	
intent	
benefiting	
overactive	
underactive	
fidgety	
distant	
childlike	
an	
adult	
friendly	
mimicked	
paralleled	
behaviors	
as	
reported	
by	
caregiver	
other	
involved	
party	
characteristics	
thoughts	
illusions	
paranoia	
grandiosity	
hallucinations	
delusions	
children	
document	
developmental	
including	
prenatal	
perinatal	
events	
school	
functioning	
requires	
information	
speak	
md	
afternoon	
complete	
intake	
paperwork	
completed	
crisis	
determine	
danger	
self	
consents	
consulting	
professional	
entities	
who	
not	
identified	
continuation	
voices	
despite	
compliance	
surprised	
continues	
disruptive	
class	
	
throwing	
pencils	
current	
assault	
documentation	
ideations	
gestures	
andor	
attempts	
employment	
situation	
five	
axis	
diagnosis	
mental	
status	
exam	
recommendations	
treatment	
daily	
living	
skills	
demonstrate	
understanding	
board	
care	
rules	
complying	
effective	
independent	
laundering	
clothes	
_x	
to_x’sweekability	
prepare	
well	
rounded	
balanced	
denies	
trauma	
abuse	
description	
specific	
determined	
develop	
healthy	
system	
attending	
12	
step	
making	
weekly	
contact	
sober	
obtaining	
utilizing	
telephone	
did	
show	
indication	
difficulty	
sleeping	
discuss	
release	
important	
person	
life	
how	
education	
about	
problem	
might	
managed	
diet	
changes	
getting	
inway	
meeting	
effectively	
manage	
anxiety	
related	
persistent	
sharing	
her	
impulsive	
group	
raising	
hand	
before	
social	
verbalizing	
depression	
feelings	
hopelessness	
schizophrenia	
responding	
internal	
establishing	
contacts	
ensure	
is	
felt	
some	
relief	
however	
commitment	
maintaining	
sobriety	
discouraged	
eye	
family	
composition	
sessions	
focus	
thewit	
present	
financial	
medical	
eligibility	
first	
age	
23	
follow	
following	
reviewed	
frequency	
possible	
may	
you	
functional	
gathered	
from	
gathering	
benefit	
receiving	
sources	
goal	
being	
focused	
today	
grades	
have	
begun	
falling	
communicating	
peers	
grooming	
personal	
hygiene	
therapy	
has	
been	
suspended	
decisions	
hashx	
severe	
major	
depressive	
sx	
helping	
strategize	
can	
accomplish	
prioritizing	
ability	
concentrate	
on	
basis	
demonstrating	
assaultive	
abusive	
presenting	
problems	
do	
begin?	
physical	
sexual	
emotional	
witnessing	
domestic	
violence	
hospitalizations	
individuals	
react	
intervention?	
see	
moving	
towards	
goal?	
very	
little	
no	
own	
triggers	
spent	
time	
processing	
through	
identifying	
obstacles	
i	
ewishes	
attend	
junior	
college	
but	
completing	
child	
response	
caregivers	
use	
tobacco	
caffeine	
must	
documented	
modified	
modify	
it	
appropriate?	
illnesses	
implement	
practices	
improve	
relationship	
will	
communicate	
anger	
one	
developing	
increased	
insight	
into	
needs	
showering	
soap	
shampoo	
individualized	
initially	
intrusive	
interrupting	
both	
presenters	
violating	
initiating	
timeout	
then	
reintegrating	
strategically	
intellectual	
intervention:	
attempt	
individual?	
interventions	
invariety	
settings	
involvement	
guardianadministrator	
office	
involving	
significant	
people	
planning	
implementation	
irrational	
stimuli	
contribute	
feeling	
anxious	
currently	
old	
caucasian	
female	
learn	
basic	
produce	
commit	
purchase	
obtain	
level	
locating	
securing	
environment	
referrals	
providers	
needed	
mannerisms	
tics	
grimacing	
marital	
conditions	
affecting	
health	
necessity	
necessity:	
functions	
still	
medically	
cleared	
evaluated	
and	
placed	
in5150	
hold	
memory	
remote	
recent	
immediate	
monitoring	
access	
progress	
activities	
up	
ensuring	
mood	
euthymic	
depressed	
elevated	
mostly	
motivation	
determination	
onceweek	
observed	
the	
barriers	
process	
explore	
orientation	
place	
relevant	
familial	
past	
include	
location	
provider	
date	
duration	
all	
legal	
law	
enforcement	
probation	
parole	
welfare	
cws	
illicit	
substance	
alcohol	
prescription	
drugs	
phone	
followup	
library	
continued	
s	
posture	
slumped	
relaxed	
stooped	
precipitating	
preplacement	
visit	
supervisor	
disposition	
subsequent	
presents	
priorities	
psychiatric	
receptive	
recognize	
cope	
esteem	
reduce	
housing	
around	
understood	
interactions	
per	
withdrawal	
actively	
participating	
available	
treatments	
three	
isolation	
gain	
approval	
based	
regards	
rehabilitation	
reintegration	
proceeded	
engage	
successfully	
inactivity	
without	
further	
two	
relaying	
therapist	
manager	
obtained	
releases	
stressors	
factors	
neglect	
prior	
medications	
intimidated	
fearful	
report	
better	
father	
divorced	
responsive	
placements	
selectnew	
seat	
where	
more	
less	
distracted	
after	
regulate	
emotions	
requesting	
out	
loud	
session	
interactive	
because	
utilization	
sand	
tray	
setbacks	
shook	
head	
question	
showing	
obstacle	
overcome	
bus	
pass	
skipping	
join	
mother	
waiting	
area	
sleep	
nightmares	
waking	
frequently	
asleep	
too	
leisure	
network	
for	
speech	
soft	
coherent	
incoherent	
rambling	
pressured	
spiritual	
beliefs	
intelligence	
good	
store	
irritability	
respectfully	
personpeople	
linking	
surgeries	
teach	
tearful	
interview	
teary	
eyed	
answering	
focusing	
times	
socially	
symptom	
reduction	
timesday	
tracking	
worked	
pts	
internally	
frustrated	
unable	
under	
circumstances	
didreceive	
services?	
understand	
reporting	
practicing	
understands	
unemployment	
utilized	
structured	
card	
game	
required	
participants	
maintain	
relapse	
writing	
10	
weeklywill	
verbalize	
statements	
acceptance	
addiction	
weight	
loss	
approx	
pounds	
month	
plans	
continuing	
work	
?	
next	
carry	
out?	
were	
present?	
such	
members	
why	
previous	
received?	
willing	
makereport	
assistance	
called	
cps	
discussed	
increasing	
“stop	
breathe	
think”	
0	
80%	
85%	
projects	
creative	
arts	
ago	
opportunities	
achieving	
acknowledged	
success	
active	
listening	
signed:	
hipaa	
privacy	
addressed	
concerns	
affirmed	
empowering	
doing	
right	
thing	
protect	
aggression	
extended	
period	
decision	
analyzed	
angry	
every	
six	
appearance	
older	
than	
stated	
younger	
disheveled	
clean	
neat	
odd	
interested	
disturbance	
grocery	
boundaries	
appropriately	
demonstrated	
evidenced	
part	
seen	
shown	
asked	
assisting	
classmates	
teacher	
lecturing	
homework	
walking	
attempted	
attentive	
bandages	
agency	
made	
behavioral	
expectations	
prompts	
physically	
aggressive	
sister	
best	
way	
bizarrely	
dressed	
body	
odour	
boredom	
calls	
brainstormed	
brainstorm	
solutions	
ways	
brief	
solution	
briefed	
parents	
bright	
bruises	
built	
rapport	
baymont	
received	
quickly	
triggers:	
calling	
friends	
calm	
down	
skill	
development	
caused	
causing	
cbt	
dbt	
techniques	
monitor	
closely	
sufficient	
prevent	
chasing	
elephant	
chronic	
clarified	
sought	
clarification	
clinical	
guide—updated	
quality	
2192010	
coached	
collaborate	
commended	
communication	
coordination	
referral	
signed	
complaints	
chores	
complied	
respond	
components	
concentrating	
confidentiality	
andlimits	
resolution	
advance	
directives	
conflict	
confronted	
confused	
connected	
comments	
connections	
conservatorship	
consulted	
continually	
along	
contracted	
coordinated	
coping	
going	
walk	
talking	
friend	
painting	
managing	
auditory	
create	
avoid	
triggering	
situations	
cued	
choices	
prescribed	
over	
counter	
dosage	
others	
grave	
disability	
decide	
decompensation	
decreasing	
demeanor	
ideation	
dental	
braces	
describe	
alternative	
developed	
individual	
directed	
attention	
acknowledgement	
receipt	
culturallinguistic	
list	
consequences	
withneed	
protective	
peterson	
clinic	
disruption	
center	
sadvc	
would	
feel	
drug	
due	
tosevere	
referring	
“upswing”	
word	
answers	
fidgeting	
most	
leaving	
duringlast	
educated	
elicited	
emaciated	
emanates	
emphasized	
employed	
positive	
reinforcements	
empowered	
overall	
encouraged	
engaged	
interaction	
entirely	
trusting	
statement	
provoke	
established	
examined	
benefits	
excoriations	
explored	
ideas	
facilitated	
lives	
state	
had	
unsure	
fighting	
concentration	
few	
four	
frustration	
groomed	
showered	
clothing	
teeth	
brushed	
deodorant	
funny	
gave	
cues	
assignment	
generated	
get	
glasses	
gonna	
tonight	
experiencing	
nightmare	
take?”	
rolled	
eyes	
informed	
several	
guided	
hospitalized	
inpast	
suicide	
cognitive	
new	
insights	
many	
interests	
sense	
humor	
worn	
uniform	
yielded	
hashhistory	
helped	
reflect	
so	
far	
persons	
accept	
condition	
chair	
halfway	
“how	
much	
longer	
blaming	
hid	
face	
behind	
hair	
hinder	
improvement	
deteriorating	
consult	
psychiatrist	
honestly	
hopes	
household	
hx	
hyperactivity	
classroom	
hypersomnia	
provoking	
trigger	
impairments	
implemented	
toward	
improving	
impulsivity	
another	
county	
provide	
psychosocial	
inability	
keep	
inadequate	
inappropriate	
express	
acceptable	
verbalizations	
inappropriately	
included	
collateral	
things	
assertive	
speaking	
herself	
indicated	
wanted	
“get	
better”	
infestations	
is:	
injection	
track	
marks	
inquired	
instructed	
interact	
otherspeers	
interpreted	
intervened	
starters	
depends	
service	
activity	
surface	
order	
ambivalent	
lack	
set	
once	
led	
parent	
guardian	
limited	
limits	
listened	
quietly	
years	
adls	
job	
educational	
groups	
each	
located	
long	
term	
looked	
maintained	
maintenance	
backup	
manifestation	
meals	
workers	
educators	
met	
minimal	
missing	
limb	
modeled	
solving	
steps	
modeling	
money	
matters	
monitored	
byas	
cycles	
efficient	
helpful	
motivated	
name	
hearing	
aids	
negative	
negotiated	
nodded	
independence	
nextmos	
non	
verbal	
number	
obese	
offered	
feedback	
ongoing	
outpatient	
return	
hesitation	
apologizing	
annually:	
stuff	
overspending	
overdressed	
overweight	
paraphrased	
partialized	
participants’	
space	
taking	
away	
cards	
participation	
vocational	
partner	
places	
performed	
special	
accommodations	
agrees	
allot	
extra	
include:	
pointed	
poor	
alternatives	
possibly	
future	
took	
lead	
formulating	
practiced	
interpersonal	
effectiveness	
praised	
substances	
solved	
explain	
prompted	
comply	
provided	
clarity	
encouragement	
guidance	
tocps	
qualifying	
questioned	
openly	
needing	
reality	
tested	
reassured	
recently	
recognizing	
recommended	
redirected	
redirection	
reflected	
refocused	
reframed	
refused	
grade	
academic	
achievements	
reframe	
experience	
reinforced	
prevention	
relates	
remained	
monkey	
indicate	
reminded	
proof	
sign	
sheet	
si	
hi	
represented	
majority	
resolved?	
respect	
responded	
restated	
informing	
materials	
risks	
role	
life:	
routine	
run	
scars	
starting	
fight	
student	
options	
seemed	
harm	
clear	
endured	
shared	
told	
anyone	
camh	
regularly	
sibling	
:	
signs	
skillbuilding	
tasks	
becoming	
increasingly	
manic	
smart	
smiled	
setting	
worker	
processed	
soiled	
small	
fornextmos	
start	
time:	
:01	
pm	
timesweek	
task	
progressive	
relaxation	
soothing	
exercises	
timeouts	
successes	
suggested	
summarized	
supplies	
supported	
supportive	
sustaining	
eteacher	
unprompted	
walks	
talkative	
tattoos	
these	
associated	
denied	
verbally	
throughout	
total	
93	
min	
paranoid	
hypomanic	
episodes	
twiceweek	
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underdressed	
underweight	
undressed	
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this	
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warranted	
used	
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open	
ended	
usefulness	
tactics	
was	
victim	
cause	
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motivational	
interviewing	
validated	
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self-care	
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/	
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cf0	
Initial	
Evaluation	
|	
Strengths	
|-	
Reason	
Problem:	
-	
Onset	
Issue:	
Symptoms,	
Functioning,	
Capacity	
[1].	
Client	
Impairment	
Mental/Emotional	
Disturbance?	
(Yes/No):	
[2].	
Significantly	
Impair	
Within	
Functioning?	
[3].	
Probability	
Deterioration	
[4].	
Child/Youth	
Developmentally	
Individually	
(Yes/No/Not	
Applicable):	
[5].	
Specialty	
Correct	
Ameliorate?	
[6].	
Given	
Nature	
Noted	
Above,	
That,	
Domain/Domains	
Treated:	
[	
]	
Home	
Yes	
Social/Peer	
Relationships	
Work/Occupation	
Health/Medical	
&	
Potential	
Exploitations	
Situation:	
Attainment,	
Highest	
Completed:	
Status):	
(How	
Living?):	
Factors:	
---	
------	
Origin:	
Family:	
Social/Friend	
Relationships:	
Network:	
Trauma/Exposure	
Trauma:	
Conservatorship,	
Court,	
Litigation,	
[1]	
Participated	
Counseling/Psychotherapy	
Past?	
Yes,	
Please	
Describe...	
Provider:	
Range	
(Start/End	
Date):	
Therapeutic	
Modalities:	
Treatment:	
Hospitalizations:	
Source	
Data:	
[2]	
Psychiatric/Medication	
When,	
Whom,	
Experience:	
Specify	
Name,	
Dosage,	
For,	
Prescribing	
Trauma?	
(Yes/No/Unknown	
Time):	
Rendered	
S/I	
H/I;	
Denied,	
Plans,	
Means,	
Intent;	
Described	
Content	
Meaningful	
Condition/Illness:	
Primary	
Physician	
(Name,	
Address,	
Phone):	
Child/Adolescent,	
Prenatal/Perinatal	
Events:	
Time?	
Specify...	
Name:	
End	
(Ie.,	
Fall	
2012	
Present):	
Use:	
Amount/Dosage:	
Frequency:	
Adverse	
Reactions?	
(Must	
Yes/No):	
Types	
Include,	
To:	
Amphetamines,	
Cocaine,	
Opiates,	
Sedatives,	
Pcp,	
Hallucinogens,	
Inhalants,	
Marijuana,	
Nicotine,	
Rx	
Drugs.	
Using	
Substances?	
Type:	
Onset:	
Dosage/Amount:	
Action	
Required?	
Impacting	
Health?	
}	
intervention.	
addition,	
reviewed,	
explained,	
Materials,	
Practices,	
Confidentiality,	
Resolution,	
Directives,	
List,	
Cultural/Linguistic	
reviewed.	
information.	
form,	
List.	
make	
’s	
assistance.	
	
CPS,	
support,	
she	
worker.	
made,	
way.	
tracking.	
task.	
techniques,	
self-soothing	
exercises,	
outs	
introduced.	
“time-outs”	
needed.	
activities.	
Communication,	
coordination,	
’s	
,	
therapist,	
manager,	
(who	
person/people)	
members,	
providers,	
educators,	
(i.e.,	
accessing,	
way)	
made.	
development,	
livi	
placement.	
Pre-placement	
visit(s)	
follow-up	
obtained.	
symptoms.	
accommodations.	
(ADLs)	
decisions)	
wishes	
morning,	
transportation,	
aids)	
accomplish.	
chores)	
symptoms/problem	
changes,	
medication)	
store)	
person/people	
plan(s)	
(if	
present,	
Collateral.	
(with	
Information)	
obstacles,	
(and	
hinder)	
functioning.	
well,	
Self,	
Others,	
disability.	
group;	
providing	
Management,	
(depends	
activity)	
¾	
/parents,	
etc.	
solutions/ways	
/’s	
Facilitated…for	
cues/prompts	
limits/boundaries	
time/	
variety	
settings.	
others/peers	
community.	
to…	
redirection.	
______	
meeting…	
…to	
goals/plan.	
/hygiene/	
safety/the	
education…	
problem-solving	
regarding…	
staff’s	
arrival,	
/seemed/	
…describe	
qualifyingstatement	
i.e.	
affect,	
/demeanor,	
talkative,	
specific,	
enforcement,	
probation,	
(when	
what)	
(CWS)	
Guardian/Administrator’s	
(prescribed	
over-the-counter)	
medication,	
frequency.	
(to	
food,	
seasonal,	
etc.)	
children,	
history,	
age,	
disheveled,	
clean,	
neat,	
appearance,	
etc)	
overactive,	
active,	
fidgety,	
distant,	
(for	
adult),	
friendly,	
impulsive,	
cooperative,	
uncooperative,	
evasive,	
gestures,	
tics,	
grimacing,	
61	
slumped,	
relaxed,	
stooped,	
soft,	
coherent,	
incoherent,	
rambling,	
pressured,	
appropriate,	
rich,	
flat,	
restricted,	
blunted,	
euthymic,	
depressed,	
elevated,	
illusions,	
paranoia,	
grandiosity,	
hallucinations,	
delusions,	
person,	
place,	
time)	
remote,	
recent,	
immediate,	
nightmares,	
frequently,	
asleep,	
little,	
deal)	
intervention;	
?	
progress,	
why.	
4	
services.	
services,	
plan.	
Min.	
illness,	
(SADVC)	
place.	
changes.	
decompensation.	
caregiver,	
classroom)	
(Be	
possible.	
goals.)	
events/stress	
(physical,	
sexual,	
emotional).	
issues)	
stressors,	
factors,	
conditions,	
job/employment/educational	
begin?)	
child’s	
assessment,	
behaviors.	
agression	
spending	
suicidal/homicidal	
ideation.	
store.	
paperwork.	
9	
female,	
sleeping,	
(Approx.	
month),	
family.	
answer,	
intake.	
hair.	
ago,	
class,	
falling.	
spells.	
;	
question.	
divorced;	
years.	
sx,	
attempts.	
Currently,	
hypersomnia,	
appetite,	
concentrating,	
memory,	
H/I.	
YCADMH	
regularly.	
behaviors,	
school,	
sister.	
year,	
goals.	
(e.g.,	
lecturing,	
homework,	
class)	
student.	
year.	
self-blaming	
attack.	
tasks.	
impulsivity.	
(include	
location,	
provider,	
date,	
care,	
possible)	
receive	
situation/employment	
caregivers).	
(abuse,	
neglect,	
illness)	
ability,	
achievements,	
participation,	
documented.	
he	
–	
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initiate	
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month…	
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page	
6197	
7197	
participationvocational	
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Approx.	
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mother.	
tray.	
questions,	
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thoughts,	
upon.	
community,	
agency.	
(such	
as,	
writing,	
walk,	
friend,	
painting)	
herself)	
anxiety.	
report,	
future.	
goals,	
session,	
today.	
(PTSD)	
manifestation.	
attack,	
better,	
area.	
and,	
situations.	
sobriety,	
however,	
compliance.	
group.	
resources,	
deteriorating.	
voices.	
intrusive;	
peers.	
time-out,	
distracted.	
time-out	
reintegration,	
disruption.	
level.	
confused,	
mimicked/paralleled	
age-appropriately	
de-escalate	
spend	
they’re	
doing,	
cancelling,	
etc?	
billable,	
particularly	
you’re	
working	
something	
like	
importance	
scheduled	
appointments	
sessions.	
•	
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later	
earlier	
spot	
reschedule	
week?	
your	
billing	
well.	
leftover,	
try	
supports	
.	
person(s):	
beliefs,	
motivation,	
substances,	
alcohol,	
tobacco,	
caffeine,	
substance,	
use,	
ideations,	
attempts,	
documented).	
yielded.	
behavior,	
documented.)	
parent/guardian,	
untitled	
project	
3.bbprojectd:	
	kelliclarktherapy.bbprojectsettings
	project.bbprojectdata
	Scratchpad.txt
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Worksheet.worksheet	
coul	
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intervention
intervention:
what
you
attempt
accomplish
safety
issues
were
present
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pounds
in
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2
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need
to
be
monitored
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see
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toward
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very
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it
as
appropriate
plans
for
continuing
work
3
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necessity:
mental
health
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functions
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is
next
step
planning
carry
out?
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of
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reported
by
9
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ability
complete
her
projects
creative
arts
groups
per
week
about
three
months
ago
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prescription
drug
accessing
resources
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services
necessary
secure
placement
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model
practice
behavior
i
acknowledged
success
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listening
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living
addition
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information
was
reviewed
explained
signed:
hipaa
privacy
addressed
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rich
flat
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right
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child
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he
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allergies
medication
food
seasonal
also
reports
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feelings
group
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staff
change
symptoms
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than
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younger
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neat
od
appear
appeared
interest
appetit
grocery
store
boundaries
arrest
history
when
wha
demonstrated
b
evidenced
part
improving
social
improve
self
awareness
reporting
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seen
assessment
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appropriateness
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goal
assisted
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increased
insight
into
assisting
specific
problem
area
related
such
at
classmates
while
teacher
lecturing
completing
homework
walking
out
class
least
twice
a
6
case
management
meetings
pla
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junior
college
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uncooperative
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illness
bandage
been
receiving
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agency

has
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began
having
great
deal
overactive
underactive
fidgety
distant
childlike
adult
friendly
behavioral
goals
plan
prompt
behaviors
caregiver
other
involved
being
physically
aggressive
sister
ha
best
way
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phone
calls
from
his
mother
boundarie
brainstormed
possible
solutions
ways
brief
solution
focused
therapy
briefed
parents
abou
bright
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built
rapport
initiating
then
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dbt
stress
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technique
changes
monitor
closely
ensure
sufficient
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characteristics
thoughts
chasing
elephant
around
sand
tray
clarified
sought
clarification
coached
on
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they
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compiled
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components
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along
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hallucinations
create
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triggering
situations
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assault
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place
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severe
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sexual
duration
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upswing
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questions
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word
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fidgeting
frequently
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but
calm
prior
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today
educated
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can
reduce
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goals.
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stressors
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sobriety
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some
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benefiting
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father
lives
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hopelessness
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including
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several
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fro
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appropriately
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showered
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gain
yielded
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so
far
significant
persons
understand
accept
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strategize
prioritizing
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approx
halfway
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much
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face
behind
hair
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improvement
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deteriorating
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psychiatrist
assaultive
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presenting
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attempts
physical
emotional
witnessing
honestly
commit
compliance
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household
chore
participating
identifying
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trigger
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implemented
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verbalizations
included
collateral
things
people
increase
motivation
chang
increasing
assertive
speaking
up
herself
mor
indicated
wanted
get
better
less
tearful
individualized
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injection
track
mark
inquired
paperwork
interact
interactions
intervened
involvement
guardian
administrator
involving
implementation
irritability
surface
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frustrates
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job
lack
se
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purchase
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once
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term
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backup
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needed
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mannerisms
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grimacing
meals
issue
workers
educators
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missing
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motivated
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aid
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behalf
intent
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answering
apologizing
process
explorer
ongoing
outpatient
return
develop
relevant
familial
relationship
tha
overweigh
page
71
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Initial
Evaluation
|
Strengths
|-
Reason
Problem:
-
Onset
Issue:
Symptoms,
Functioning,
Capacity
[1].
Client
Impairment
Mental/Emotional
Disturbance?
(Yes/No):
[2].
Significantly
Impair
Within
Functioning?
[3].
Probability
Deterioration
[4].
Child/Youth
Developmentally
Individually
(Yes/No/Not
Applicable):
[5].
Specialty
Correct
Ameliorate?
[6].
Given
Nature
Noted
Above,
That,
Domain/Domains
Treated:
[
]
Home
Yes
Social/Peer
Relationships
Work/Occupation
Health/Medical
&
Potential
Exploitations
Situation:
Attainment,
Highest
Completed:
Status):
(How
Living?):
Factors:
---
------
Origin:
Family:
Social/Friend
Relationships:
Network:
Trauma/Exposure
Trauma:
Conservatorship,
Court,
Litigation,
[1]
Participated
Counseling/Psychotherapy
Past?
Yes,
Please
Describe...
Provider:
Range
(Start/End
Date):
Therapeutic
Modalities:
Treatment:
Hospitalizations:
Source
Data:
[2]
Psychiatric/Medication
When,
Whom,
Experience:
Specify
Name,
Dosage,
For,
Prescribing
Trauma?
(Yes/No/Unknown
Time):
Rendered
S/I
H/I;
Denied,
Plans,
Means,
Intent;
Described
Content
Meaningful
Condition/Illness:
Primary
Physician
(Name,
Address,
Phone):
Child/Adolescent,
Prenatal/Perinatal
Events:
Time?
Specify...
Name:
End
(Ie.,
Fall
2012
Present):
Use:
Amount/Dosage:
Frequency:
Adverse
Reactions?
(Must
Yes/No):
Types
Include,
To:
Amphetamines,
Cocaine,
Opiates,
Sedatives,
Pcp,
Hallucinogens,
Inhalants,
Marijuana,
Nicotine,
Rx
Drugs.
Using
Substances?
Type:
Onset:
Dosage/Amount:
Action
Required?
Impacting
Health?
}
intervention.
addition,
reviewed,
explained,
Materials,
Practices,
Confidentiality,
Resolution,
Directives,
List,
Cultural/Linguistic
reviewed.
information.
form,
List.
make
’s
assistance.

CPS,
support,
she
worker.
made,
way.
tracking.
task.
techniques,
self-soothing
exercises,
outs
introduced.
“time-outs”
needed.
activities.
Communication,
coordination,
’s
,
therapist,
manager,
(who
person/people)
members,
providers,
educators,
(i.e.,
accessing,
way)
made.
development,
livi
placement.
Pre-placement
visit(s)
follow-up
obtained.
symptoms.
accommodations.
(ADLs)
decisions)
wishes
morning,
transportation,
aids)
accomplish.
chores)
symptoms/problem
changes,
medication)
store)
person/people
plan(s)
(if
present,
Collateral.
(with
Information)
obstacles,
(and
hinder)
functioning.
well,
Self,
Others,
disability.
group;
providing
Management,
(depends
activity)
¾
/parents,
etc.
solutions/ways
/’s
Facilitated…for
cues/prompts
limits/boundaries
time/
variety
settings.
others/peers
community.
to…
redirection.
______
meeting…
…to
goals/plan.
/hygiene/
safety/the
education…
problem-solving
regarding…
staff’s
arrival,
/seemed/
…describe
qualifyingstatement
i.e.
affect,
/demeanor,
talkative,
specific,
enforcement,
probation,
(when
what)
(CWS)
Guardian/Administrator’s
(prescribed
over-the-counter)
medication,
frequency.
(to
food,
seasonal,
etc.)
children,
history,
age,
disheveled,
clean,
neat,
appearance,
etc)
overactive,
active,
fidgety,
distant,
(for
adult),
friendly,
impulsive,
cooperative,
uncooperative,
evasive,
gestures,
tics,
grimacing,
61
slumped,
relaxed,
stooped,
soft,
coherent,
incoherent,
rambling,
pressured,
appropriate,
rich,
flat,
restricted,
blunted,
euthymic,
depressed,
elevated,
illusions,
paranoia,
grandiosity,
hallucinations,
delusions,
person,
place,
time)
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recent,
immediate,
nightmares,
frequently,
asleep,
little,
deal)
intervention;
?
progress,
why.
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services.
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plan.
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illness,
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place.
changes.
decompensation.
caregiver,
classroom)
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possible.
goals.)
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sexual,
emotional).
issues)
stressors,
factors,
conditions,
job/employment/educational
begin?)
child’s
assessment,
behaviors.
agression
spending
suicidal/homicidal
ideation.
store.
paperwork.
9
female,
sleeping,
(Approx.
month),
family.
answer,
intake.
hair.
ago,
class,
falling.
spells.
;
question.
divorced;
years.
sx,
attempts.
Currently,
hypersomnia,
appetite,
concentrating,
memory,
H/I.
YCADMH
regularly.
behaviors,
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sister.
year,
goals.
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lecturing,
homework,
class)
student.
year.
self-blaming
attack.
tasks.
impulsivity.
(include
location,
provider,
date,
care,
possible)
receive
situation/employment
caregivers).
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neglect,
illness)
ability,
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voices.
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tx560
tx1120
tx1680
tx2240
tx2800
tx3360
tx3920
tx4480
tx5600
tx6160
tx6720
cf2
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'92sweekability
'93stop
think
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'97updated
'93upswing
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re-framed
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/
(openly)
open-ended
setbacks,
anxiety,
anger,
CBT,
DBT,
(techniques)
plan,
and

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 3878 boilerplate words
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