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able


able
deescalate

able
independently
identify

accessing
services
necessary
secure
placement


accompanying
in
public
model
practice
appropriate
behavior


affect
appropriate
rich
flat
restricted
blunted
etc


agreed
utilize
peer
support
community
resources
or
call
clinician
if
feels

allergy
medication
food
seasonal
etc


also
reports
frequent
crying
spells


answered
a
couple
questions
“yes”
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answer


any
change
symptoms
in
last
year

appeared

appeared
pleased
with
goals
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upon
expressed
that
could

appears

appetite

appreciative
of
intervention
reports
drop

are
there
any
safety
issues
that
need
to
be
monitored?

arrest
history
what


arrested

asking
repeat
questions
while
discussing
suicidal
or
homicidal

assessed
be
at
low
risk


assessment
regarding
appropriateness
placement


at
least
twice
a
week
fornex
months
during
case
management
meetings
plan

attack
addition
explained
post
traumatic
stress
disorder
ptsd


attitude
cooperative
uncooperative
evasive
etc


authorization
form

awareness
illness

be


began
having
great
deal


behalf
with
intent
benefiting


behavior
overactive
underactive
fidgety
distant
childlike
an
adult
friendly


behavior
mimicked
paralleled


behaviors
as
reported
by
caregiver
or
other
involved
party

characteristics
thoughts
illusions
paranoia
grandiosity
hallucinations
delusions


children
document
developmental
history
including
prenatal
perinatal
events


children
document
school
functioning
assessment
form
requires
that
information

plan

clinician
able
speak
md
that
afternoon


complete
intake
paperwork


completed
crisis
assessment
determine
danger
self


consents

consulting
other
necessary
professional
entities
who
are
not
identified
as


continuation
voices
despite
medication
compliance
reported
surprised

continues
be
disruptive
class
e
g
throwing
pencils

current
assessment
assault
risk
documentation
as
what
information
that
assessment

current
assessment
suicidal
ideations
gestures
andor
attempts
documentation
as


current
employment
situation


employment
history

current
five
axis
diagnosis

current
mental
status
exam

current
plan


current
recommendations
treatment

daily
living
skills

demonstrate
an
understanding
board
care
rules
complying
with
rules

demonstrate
effective
independent
living
skills
laundering
clothes
at
least
_x


demonstrate
to_x’sweekability
prepare
well
rounded
balanced

denies


denies
any
trauma
or
abuse


description
specific


determined
be

develop
healthy
support
system
attending
at
least
12
step
meetings
week
as

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healthy
support
system
making
weekly
contact
with
sober
support

develop
healthy
support
system
obtaining
utilizing
at
least
telephone

did
not
show
any
indication


difficulty
sleeping


discuss
information


discussing
release
information
an
important
person
in
life
how


education
about
how
symptoms
problem
behaviors
might
be
managed
diet
changes


education
regarding
how
problem
behaviors
are
getting
inway
meeting
goals

effectively
manage


anxiety


related


other
persistent
mental
illness
sharing


her

effectively
manage
impulsive
behavior
during
group
raising
hand
before

effectively
manage
social
anxiety
verbalizing
at
least
symptoms
anxiety
at

effectively
manage
symptoms
depression
e
g
feelings
hopelessness


effectively
manage
symptoms
related
schizophrenia
e
g
responding
internal

establishing
contacts
that
are
necessary
to
ensure
treatment
plan
is
effectively

expressed
that
felt
some
relief
discussing
attack
however
not

expressed
commitment
maintaining
sobriety
however
is
discouraged


eye
contact

family
composition

family
sessions
with
focus
benefiting
thewit
present
are
also

financial
including
medical
eligibility


first
at
age
23


follow


following
information
reviewed


frequency
symptoms
behaviors
be
as
specific
as
possible
may
you


functional
skills

gathered
information
from

gathering
information
that
benefit
receiving
necessary
services
from
sources

goal
that
is
being
focused
today


grades
have
begun
falling


great
difficulty
communicating
peers
or
family


grooming
personal
hygiene
skills


group
therapy

has
been
suspended
from

has
difficulty
making
decisions


hashx


hashx
severe
major
depressive
sx


helping
strategize
about
what
can
accomplish
prioritizing

her
ability
to
concentrate
focus
on
a
daily
basis
demonstrating


history
assaultive
or
abusive
behavior
if
there
is
history
behavior


history
presenting
problems
do
symptoms
begin?


history
trauma
or
abuse
physical
sexual
emotional
witnessing
domestic
violence

hospitalizations

how


how
did
individuals
react
to
intervention?

how
do
you
see
moving
or
not
moving
towards
goal?
if
very
little
or
no

identified
own
triggers
spent
some
time
processing
through
feelings


identify


identifying
obstacles
i
ewishes
attend
junior
college
but
has
difficulty
getting

if
completing
child
assessment
also
document
response
of
caregivers


if
there
is
any
current
use
tobacco
or
caffeine
frequency
use
must
be
documented


if
you
modified
intervention
how
did
you
modify
it
as
appropriate?

illnesses

implement
healthy
personal
hygiene
practices
attending
community
peer

improve
relationship
skills
will
identify
communicate
triggers
anger


improve
self
awareness


improve
social
skills
identifying
verbalizing
one
difficulty
related
social

community
group
case
management
medication
support

crisis

developing
increased


developing
insight
into

independently
demonstrate
self
care
needs
showering
soap
shampoo

individualized


initially
disruptive
intrusive
interrupting
both
presenters
violating
other

initiating
timeout
then
reintegrating
into
group
strategically
helping

intellectual
functioning

intervention:
what
did
you
attempt
to
accomplish
with
individual?

interventions

invariety
settings


involvement
public
guardianadministrator
office


involving
identified
significant
support
person
people
planning
implementation

irrational
internal
stimuli
that
contribute
feeling
anxious
weekly

is
currently


is
not

is
year
old
caucasian
female
presenting


learn
basic
hygiene
grooming
skills


will
produce


commit
to
daily
hygiene

learn
basic
hygiene
grooming
skills


will
purchase


obtain


at
least


grooming

level


locating
securing
an
appropriate
living
environment

making
referrals
providers
needed
services

mannerisms


gestures


tics
grimacing
etc


marital
status

medical
conditions
that
could
be
affecting
mental
health

medical
history

medical
issues

medical
necessity

medical
necessity:
what
are
mental
health
or
community
functions
that
are
still
not

medically
cleared
then
evaluated
crisis
and
placed
in5150
hold


medication
referrals


memory
remote
recent
immediate
etc


monitoring
ensure
access
services

monitoring
progress

monitoring
activities
necessary
follow
up
ensuring
that
resources
that


mood
euthymic
depressed
elevated
etc


mostly


motivation
change

needs
determination

onceweek
community
group
as
observed
by
the
identify
barriers


one
week
life
skills
group
as
observed
by
the
process
explore

orientation
person
place
time


other
relevant
history
familial
relationship
issues


past
hospitalizations
include
location
provider
date
duration
care
if
at
all
possible


past
legal
involvement
law
enforcement
probation
or
parole

past
or
current
involvement
child
welfare
services
cws


past
use
illicit
substance
alcohol
tobacco
caffeine
abuse
prescription
drugs

placed
phone
call


placement
placement
followup

plan
library
continued

plan
s


posture
slumped
relaxed
stooped
etc


precipitating
events
stress

preplacement
visit
s


present
supervisor
disposition
services
subsequent
authorization


presenting
problem
including
current
symptoms
relevant
conditions
affecting
mental

presents


priorities

psychiatric
symptoms

receptive

recognize
manage
cope
symptoms
depression
e
g
low
self
esteem


reduce
feelings
anxiety
about
housing
verbalizing
thoughts
related
housing

reduce
feelings
anxiety
around
not
being
understood
verbalizing
thoughts

reduce
social
anxiety


initiating
social
interactions


per
week


as
observed


persistent
mental
illness
identifying
emotional

reduce
social
withdrawal
actively
participating
available
treatments
social

reduce
social
withdrawal
identifying
verbalizing
three
triggers
isolation
as

reduce
need
gain
approval
from
by
identifying
verbalizing
at
least
one

referrals
other
providers
based
on
level
services
needed

regards
past
use
date
last
use
must
be
documented


rehabilitation

reintegration
proceeded
engage
successfully
inactivity
without
further

relationship
skills
identifying
two
social
interactions
communicating

relaying
information
that
is
medically
necessary
from
therapist
case
manager
or

release
information
obtained


releases

relevant
conditions
affecting
mental
health
physical
stressors
relationship
factors


relevant
family
history
abuse
neglect
substance
abuse
history
mental
health
history


relevant
prior
medications

reported
feeling
intimidated
fearful
at
first
regarding
report
however


reported
that
felt
better
observed

reports

reports
that


reports
that
father
are
divorced


responsive

securing
housing
or
placements

selectnew
seat
where
could
be
more
focused
less
distracted
after
timeout

self
regulate
emotions
and
behaviors
requesting
speak
out
loud
group
_x

session
interactive
because
of
utilization
sand
tray


sessions
with
family
if
are
identified
as
significant
support
person
people


setbacks


shook
her
head
response
to
question


showing
how
some
obstacle
might
be
overcome
how
obtain
bus
pass

skipping
out
of
office
join
her
mother
in
waiting
area


sleep
nightmares
waking
frequently
difficulty
falling
asleep
sleeping
too
little


social
leisure
skills

social
support
network
for
child
assessment
document
caregivers


speech
soft
coherent
incoherent
rambling
pressured
etc


spiritual
beliefs
family
support
motivation
intelligence
good

store


stress
management
skills
reduce
irritability
respectfully
verbalizing

support
personpeople
linking
other
necessary
services

support
services

surgeries

symptoms


teach


tearful
during
interview

teary
eyed
while
answering
questions


appeared
have
difficulty
focusing

three
times
week
life
skills
group
as
observed
by
the
identify
socially

three
times
week
symptom
reduction
group
as
observed
by
the


timesday

tracking
worked
pts
identifying
how
felt
internally
frustrated


twice
week
symptom
reduction
group
as
observed
by
the
identify

unable


under
what
circumstances
didreceive
services?


understand
need
good
hygiene
reporting
practicing
healthy
personal

understands
session
is
an
assessment
still
needs
approval
services


unemployment

utilized
structured
card
game
that
required
participants
maintain
focus

weekly
life
skills
group
as
observed
by
the
identify
internal
barriers


weekly
will
reduce
risk
relapse
identifying
writing
at
least
10
triggers
e
g


weeklywill
verbalize
at
least
statements
acceptance
regarding
her
addiction
as

weight
loss
approx
10
pounds
in
past
month
having


what
are
plans
continuing
work
?

what
is
the
next
step
you
are
planning
to
carry
out?


what
safety
issues
were
present?

who
are
not
identified
as
support
person
people
such
as
family
members


why
were
previous
services
received?

willing
discuss

willing
makereport
assistance
called
cps


work


discussed
goals
increasing
appropriate
“stop
breathe
think”
0
timesday
80%
of
the
time
during
first
month
85%
of
time
next
month
as
reported

ability
to
complete
her
projects
during
creative
arts
group
times
per
week
for
next

about

about
three
months
ago

accessing
community
resources

accessing
opportunities

achieving
goals
acknowledged
acknowledged

acknowledged
success

active
listening
active
listening
skills

activities
daily
living
addition
following
information
reviewed
explained
signed:
hipaa
privacy
addressed
concerns

affirmed

agreed

agreed
that
it
empowering
that
doing
right
thing
protect
her
child

aggression
all
possible

an
education
an
extended
period
of
time
an
impulsive
decision
analyzed

anger
angry
feelings
during
group
week
every
week
six
months
as
observed

anxiety
anxiety
anger
etc
any
change

appearance
etc

appearance
older
than
stated
age
younger
than
stated
age
disheveled
clean
neat
odd
appeared
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appeared
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appears

appetite
disturbance
appropriate

appropriate
behavior
in
grocery
store

appropriate
boundaries

appropriately
as
demonstrated

as
evidenced

as
part

as
reported
as
reported

as
seen

as
shown
asked

assisting
assisting
with
specific
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related
such
activities
as
activities
daily
at

at
classmates
while
the
teacher
is
lecturing
not
completing
homework
walking
out
class

attempted

attentive

bandages
been
receiving
services
through
agency
for
past
year
has
made
before

behavior
behavior

behavioral
expectations
behavioral
goals
plan

behavioral
prompts
behaviors
being
physically
aggressive
younger
sister
has
best
way

better

bizarrely
dressed
body
odour
boredom
phone
calls
from
mother

boundaries
brainstormed

brainstorm
possible
solutions
ways

brief
solution
focused
therapy

briefed
parents
etc
about
bright
affect

bruises
built
rapport

but

baymont
support
received
from
group
quickly
identified
two
triggers:
calling
friends
calm
down
case
management
is
not
skill
development
assistance
daily
living
caused

causing
disturbance

cbt
dbt
stress
reduction
techniques

changes
plan
monitor
closely
ensure
has
sufficient
support
prevent
chasing
elephant
around
sand
tray

chronic
illness

clarified

clarified
sought
clarification

clinical
guide—updated
quality
management
2192010
clothes
coached

collaborate
overcome
obstacles
or
how
might
support
not
commended

communication
coordination
referral
community

community
family
agency
signed
completed
treatment
plan

complaints

completing
daily
weekly
chores
for
next
six
months

complied
expectations
did
not
respond
components
assessment
continued
concentrating
as
observed

confidentiality
andlimits
confidentiality
problem
resolution
advance
directives

conflict
confronted

confronted
about

confused
responding
internal
stimuli
connected
comments

connections

conservatorship
office
development
of
treatment
plan

consulted

continually

continues
have
difficulty
getting
along
younger
sister

contracted

coordinated

coping
skills
anxiety
such
as
writing
going
for
walk
talking
to
friend
or
painting

coping
skills
managing
auditory
hallucinations
for
next
six
months

create
plan
avoid
triggering
situations

cued

current
choices
current
legal
involvement
law
enforcement
probation
or
parole
current
living
situation
current
medication
prescribed
or
over
the
counter
medication
document
dosage

currently
reports

danger
others
or
level
grave
disability

decide

decompensation

decreasing

demeanor

demonstrated

denies
any
suicidal
homicidal
ideation

dental
braces
depressed

depression
describe

describe
alternative
her
behavior
developed
developed

development
individual
group
identify
verbalize
barriers
focusing

difficulty
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difficulty
focusing
class

directed
comments

directed
attention
directives
acknowledgement
receipt
form
culturallinguistic
needs
provider
list

discussed
discussed

discussed
consequences

discussed
withneed
report
information
child
protective
services

discuss
symptoms
explained
md
peterson
clinic
md
disruption

disruptive
behaviors

domestic
violence
center
sadvc
where
reported
would
feel
out
place
plan

drug
use

due

due
tosevere
mental
illness
is
not
referring
sexual
assault

during
an
“upswing”
during
intake
answered
questions
one
word
answers
fidgeting
frequently

during
most
of
session
but
appeared
calm
prior
leaving
today

during
intake

duringlast

educated

educated
about
medications
how
can
reduce
symptoms

elicited

emaciated
emanates

emphasized

employed
positive
reinforcements

empowered
overall
anxiety

encouraged

engaged

engaged
positive
social
interaction
entirely
trusting
clinician
statement
that
did
not
provoke
attack
is
fearful

established

etc

evaluated

examined

examined
benefits
consequences

excoriations
explained

explained
signed

explored

explored
ideas
about
expressed
facilitated
for
an
extended
period
father
father
lives
out
state
has
had
feelings

feelings
hopelessness
verbalizing
how
is
feeling
during
community
feels
unsure
fighting
peers
at
school

flat
affect

focus
concentration
focused

focused
issues

following

for
the
next
few
months

four

frequency

friend
friendly
disposition
from
frustration
functions
meetings
appropriately
groomed
showered
clean
clothing
teeth
brushed
deodorant

funny
gave
cues
prompts

gave
homework
assignment

generated
gestures
andor
attempts
information
must
be
documented

get
there
glasses
gonna
sleep
tonight
experiencing
nightmare
going
to
take?”
rolled
her
eyes
informed
that
there
were
several
guided

has
has

has
been
hospitalized
three
times
inpast
year
suicide
attempts

has
cognitive
ability
learn
new
coping
skills
gain
new
insights
has
many
interests
has
sense
humor
has
worn
uniform
has
yielded

hashhistory

health
helped

helped
reflect
progress
have
made
so
far

helping
significant
support
persons
understand
accept
condition
her
chair
approx
halfway
through
assessment
asked
“how
much
longer
is
thing
her
self
blaming
about
attack

hid
her
face
behind
hair

hinder
some
area
improvement
functioning


condition
is
deteriorating
clinician
consult
psychiatrist
regarding
her

history
suicidal
ideations
gestures
andor
attempts
if
there
is
history
ideations

honestly
commit
maintaining
medication
compliance
sobriety
support
from
hopelessness
hopes

household
chores

hx

hygiene
hygiene
skills
as
observed
by
for
next
months

hyperactivity
in
classroom

hypersomnia

identified
identified

identify
barriers
participating
group
for
the
next
six
months

identifying

identifying
anxiety
provoking
trigger
for
next
months
as
reported
observed

impairments
implemented
implemented
that
progress
toward
goals
are
being
made

improving
social
skills
impulsive
etc

impulsivity


another
county


anxiety
level


being
able
provide
information
psychosocial
assessment
is
intervention


planning


session
inability
keep
employment
inadequate
ability

inappropriate
behaviors
express
acceptable
behaviors
verbalizations
for
next
six
months

inappropriate
interaction
others
inappropriate
sexual
behavior
inappropriately
included
collateral

including

including
throwing
things
at
other
people

increasing
assertive
behaviors
such
as
speaking
up
herself
feel
more
indicated
that
very
much
wanted
“get
better”
have
less
anxiety
tearful
individual
therapy
infestations
information
included
in
assessment
is:
information
must
be
documented

informed
informed

initially
injection
track
marks
inquired
about

instructed

interact
otherspeers

interactions

interactions
peers

interactions
twice
week
for
next
months
as
observed

interpreted

intervened

intervention
intervention
starters
depends
service
activity

irritability
that
surface
during
interactions
at
least
times
week
as
observed
by
for

is

is
accessing
order
meeting
treatment
goals
are
assisting

is
ambivalent
toward
is
frustrated
lack
access
lack
skill
set
lack
support
learn

least
once
a
week
as
observed
by
for
next
months

led
practicing

level
involvement
from
the
parent
guardian
andor
limited
response
limits
boundaries
linking
pts
necessary
services
listened
closely

listened
quietly
little
contact
several
years

living
adls

living
conditions
job
employment
educational
stressors
etc

living
skills
groups
each
week
as
reported
observed

located
long
term
goals

looked

low
appetite

made
eye
contact
made
little
eye
contact

maintained
maintenance

making

making
backup
plan

manage
manifestation

meals
as
observed

medical
providers
social
workers
educators

medication

meeting
met

met
complete

minimal
access
minimal
support
missing
limb
modeled

modeled
appropriate
communication
skills

modeled
problem
solving
steps

modeling
modified
her
behavior
money
matters
monitored
monitored

month
as
reported
byas
observed

months

months
as
observed

mood

mood
cycles

most
efficient
helpful
way

motivated
therapy
name
necessary
hearing
aids

negative
and
positive
social
interaction
times
week
for
next
months

negotiated
nodded
new
coping
skills
increasing
emotional
independence
each
week
fornex
months
as
nextmos

nightmares

non
verbal

number
of
clean
sober
people
as
reported
weekly

obese
observed
observed

observed
by
week
every
week
six
months

obtaining
information
from
an
important
person
pts
life
offered

offered
feedback
older
than
stated
age
ongoing
outpatient
mental
health
services
and
mother
return
develop
plan

ongoing
outpatient
mental
health
services
will
return
develop
plan

questions
as
evidenced
her
frequent
hesitation
answering
questions
apologizing

other
paperwork
be
completed
annually:
other
stuff
other
than
others
out

overspending

overdressed
overweight
paraphrased

parent
partialized

participants’
space
taking
away
cards
talking
over
her
peers

participation
vocational
goals
must
be
documented

partner
people
as
reported

people
places
things
as
reported
observed

performed

personal
safety
the
physical
symptoms
and
need
special
accommodations
md
agrees
agreed
allot
extra
placement
services
may
include:
plans

pointed
out
consequences

poor
memory

possible
alternatives

possibly
other
children
in
future
took
lead
formulating
her
goals

practice
practiced

practiced
assertive
communication
skills
interpersonal
effectiveness
practiced
effective
communication
skills
decreasing

practices
confidentiality
andlimits
confidentiality
problem
resolution
advance
praised
praised

present
use
illicit
substances
alcohol
tobacco
caffeine
abuse
prescription
drugs
presenting
problem
previous
mental
health
providers
include
location
provider
date
duration
care
if
at
priorities

problem
solved
problems
family
problem
solving
session

progress
progress
explain
why

prompted

prompted
comply
expectations
provided
clarity

provided
frequent

provided
insight

provided
support
encouragement
guidance
as
provided
information
tocps
provider
list
acknowledgement
receipt
form
culturallinguistic
issues
were
also
psychiatric
hospitalizations

psychiatrist
another
person

psychosocial
assessment
is
intervention
addition
following
information

public
accompanying
to
grocery
store
practicing
qualifying
statement

questioned
openly

questions
still
needing
be
answered

reality
tested
reassured

received
a
phone
call
from

recent

recently

recognizing
triggers

recommended

redirected
redirected

redirection

reflected

refocused

reframed
reframed

refused

regarding
regarding

regarding
grade
school
academic
ability
achievements
any
special
education
regarding
making
report
attempted
reframe
experience
an
empowering
way

reinforced

relapse
prevention
relates

remained
non
verbal
but
pointed
to
monkey
then
herself
indicate
monkey
reminded
reported
reported
proof
of
completed
sign
in
sheet

reporting

reports
no
si
or
hi

reports
that
is
having
intrusive
thoughts

represented
her
then
pointed
an
elephant
mother
indicate
that
elephant
represented
mother
then
spent
majority
of
time
intake
showing
monkey
resolved?
resources
at
least
times
week
as
observed
by
fornex
months

respect

responded

responded
age
appropriately
response
restated

reviewed
reviewed

reviewed
explained
signed:
informing
materials
hipaa
privacy
practices

reviewed
current
coping

risks
consequences

role

role
in
life:
role
modeled
routine
as
reported
observed

run
out
scars
school
once
in
past
months
due
starting
fight
another
student

school
work
options
for
next
six
months

seemed
seemed

self
harm
self
report

set
clear

sexual
assault
endured

shared


has
not
told
anyone
about
assault


is
currently
receiving
medication
services
from
camh
reports
taking
her
medication
regularly

sibling
significant
support
person
s
:
signs

skillbuilding
tasks

skills

sleep
disturbance

sleeping
well
is
becoming
increasingly
manic
appears
be
hearing
voices
sleeping
great
deal

smart
smiled
social
setting
social
worker
after
report
made
processed
experience

soiled

some
small
progress
goals

speaking
out
loud
times
week
as
observed
by
fornextmos

start
time:
:01
pm
stimuli
verbalizing
coping
skills
timesweek
as
observed
by
fornex
months

structured
task
progressive
relaxation
techniques
self
soothing
exercises
timeouts
successes
such
as
suggested
suggested

summarized

supplies
every
month
as
reported
observed

supported
supportive
assistance
sustaining
her
focus
activities

symptom
management
symptoms
and
behaviors

symptoms
anxiety
appropriate
coping
techniques
times
week
for
next
months

symptoms
as
reported
by
caregiver
or
other
involved
party
i
eteacher
reporting
taking
medication
unprompted
by
for
the
next
six
months

taking
walks
talkative

tattoos
that

then

these
feelings
week
during
process
groups
as
observed
by
for
six
months

thoughts
associated
triggers
utilizing
cognitive
behavioral
techniques
began

thoughts
denied
any
currently
verbally
contracted
safety
throughout

time
see

times
week
as
observed
by
fornextmos

today

total
time:
93
min

triggers

triggers
communicating
related
feelings
times
per
week
as
observed
by
for
next

triggers
paranoid
ideation
or
hypomanic
episodes
for
next
six
months

twiceweek
socialization
group
as
reported
by
the
verbalize
effective
two

underdressed
underweight
undressed
uninterested
unshaven
up
in
the
morning
does
not
know
how
to
use
public
transportation
has
not
gotten
upon
this
arrival

use
“timeouts”
as
warranted
needed
activities
were
utilized
pts

use
cognitive
techniques
consult
psychiatrist
regarding
possible
medication
used
empathy
understand

used
humor

used
open
ended
questions
explore

usefulness

utilized
cognitive
tactics
understand
that
was
victim
did
not
cause
utilized
mindfulness
techniques

utilized
motivational
interviewing
techniques
validated
point
view
feelings

voices

wants
vs
needs

watching
funny
movies
were
also
introduced
these
were
utilized
pts
focusing
activity
as
well
as

what
information
that
assessment
has
yielded

which
result

which
soon

while
homeless
last
year

who
indicated

with
focus

without
prompting
format
least
_x
week
every
week
for
months
as
reported

worked

worn

worn
jewellery
worthlessness
low
self
esteem
verbalizing
feelings
related
her
mental
illness
would
also
be
pertinent
information

wounds
writingplan
goals

week
every
week
six
months
as
observed

years
younger
than
stated
age
is
obese
is
overweight
is
underweight
is
emaciated
appears
older
than
stated
age
appears
younger
than
stated
age
is
unshaven
has
wounds
has
scars
has
bruises
has
bandages
has
tattoos
has
worn
jewellery
has
glasses
has
dental
braces
has
missing
limb
emanates
body
odour
has
worn
soiled
clothes
has
excoriations
has
infestations
has
injection
track
marks
has
signs
of
self
harm
is
undressed
is
underdressed
is
overdressed
is
bizarrely
dressed
was
tearful
during
interview
Information
included
in
the
assessment
is:

Presenting
problem,
including
the
current
symptoms
and
relevant
conditions
affecting
mental

Psychiatric
symptoms

family
composition

Medical
History

Current
Five
Axis
Diagnosis

Current
Mental
Status
Exam

Current
Recommendations
for
treatment
Other
paperwork
to
be
completed
annually:

Releases

Authorization
Form

Medical
Necessity

Consents

Client
Plan

Financial,
including
Medi-Cal
eligibility

and
any
change
of
symptoms
in
the
last
year
Any
change
in

10

amount

Behaviors
reported


caregiver
or
other
involved
party

completed

crisis

discouraged

evaluated


every
month


however


identifying


improve

improve
social
skills

improving

initiating

initiating
#
social
interactions

week

internal
barriers

living
skills
groups
each
week

reported

observed


month

reported


observed


next
six
months

number

clean
sober
person

reported

weekly

observed


observed



part


people

people
places
things

placed

5150
hold

proof


reduce
risk

relapse


reduce
social
anxiety


reported


reported



reporting
reporting


routine

self
awareness


social
skills

Socialization

supplies

Symptoms


taking
medication
teacher

time
out

triggers


Twice
week

unprompted



verbalize
effective
was
medically
cleared


week
every
week

#
months

Weekly

without
prompting




writing


decrease
symptoms
of
increase
appropriate

increase
level
of

0
times
a
day
to
3
times
a
day
as
reported
by
as
evidenced
by

as
seen
by

as
demonstrated
by
Twice
a
week
in
Socialization
Group
and
as
reported
by
staff,
the
pt
will
verbalize
effective
coping
skills
for
managing
auditory
hallucinations
for
the
next
six
months.

Three
times
a
week
in
Symptom
Reduction
group
and
as
observed
by
staff,
the
pt
will
identify
barriers
to
participating
in
group
for
the
next
six
months.

Once
a
week
in
Community
group
and
as
observed
by
staff,
the
pt
will
identify
barriers
to
completing
daily/weekly
chores
for
the
next
six
months.

Once
a
week
in
Life
Skills
group
and
as
observed
by
staff,
the
pt
will
process
and
explore
school/work
options
for
the
next
six
months.

Twice
a
week
in
Symptom
Reduction
group
and
as
observed
by
staff,
the
pt
will
identify
triggers
of
paranoid
ideation
or
hypomanic
episodes
for
the
next
six
months.

Weekly
in
Life
Skills
group
and
as
observed
by
staff,
the
pt
will
identify
internal
barriers
to
taking
medication
unprompted
by
staff
for
the
next
six
months.

Three
times
a
week
in
Life
Skills
group
and
as
observed
by
staff,
the
pt
will
identify
socially
inappropriate
behaviors
and
express
acceptable
behaviors/verbalizations
for
the
next
six
months.

pt
will
reduce
social
anxiety
by
initiating
3
social
interactions
per
week
as
observed
by
staff
for
the
next
6
months.

pt
will
reduce
social
anxiety
related
to
his
persistent
mental
illness
by
identifying
emotional
triggers
and
communicating
related
feelings
2
times
per
week
as
observed
by
staff
for
the
next
6
months.

pt
will
effectively
manage
social
anxiety
by
verbalizing
at
least
3
symptoms
of
anxiety
at
least
once
a
week
as
observed
by
staff
for
the
next
6
months.

pt
will
effectively
manage
anxiety
related
to
h/her
persistent
mental
illness
by
sharing
h/her
symptoms
of
anxiety
and
appropriate
coping
techniques
3
times
a
week
for
the
next
6
months.

pt
will
reduce
feelings
of
anxiety
around
not
being
understood
by
verbalizing
thoughts
__x/week
every
week
for
six
months
as
observed
by
staff.

pt
will
reduce
feelings
of
anxiety
about
housing
by
verbalizing
thoughts
related
to
housing
__x/week
every
week
for
six
months
as
observed
by
staff.


As
part
of
improving
social
skills,
pt
will
improve
self-awareness
by
reporting
to
staff
1
negative
and
1
positive
social
interaction
2
times
a
week
for
the
next
6
months.

pt
will
improve
social
skills
by
identifying
and
verbalizing
one
difficulty
related
to
his
social
interactions
twice
a
week
for
the
next
6
months
as
observed
by
staff.

To
improve
relationship
skills,
pt
will
identify
and
communicate
triggers
of
anger
and
irritability
that
surface
during
interactions
at
least
2
times
a
week,
as
observed
by
staff,
for
the
next
6
mos.

pt
will
reduce
social
withdrawal
by
actively
participating
in
available
treatments/social
resources
at
least
3
times
a
week
as
observed
by
staff
for
the
next
6
months.

pt
will
reduce
social
withdrawal
by
identifying
and
verbalizing
three
triggers
of
isolation
as
observed
by
staff
__x/week
every
week
for
six
months.

pt
will
increase
relationship
skills
by
identifying
two
social
interactions
and
communicating
these
feelings
__x/week
during
process
groups
as
observed
by
staff
for
six
months.

At
least
twice
a
week
for
the
next
6
months
(during
case
management
meetings;
plan
development;
individual,
group,
pt),
pt
will
identify
and
verbalize
barriers
to
focusing
and
concentrating
as
observed
by
staff.

pt
will
increase
her
ability
to
concentrate
and
focus
on
a
daily
basis
by
demonstrating
the
ability
to
complete
her
projects
during
Creative
Arts
groups
2
times
per
week
for
the
next
6
months,
as
observed
by
staff.

pt
will
understand
the
need
for
good
hygiene
by
reporting
and
practicing
3
healthy
personal
hygiene
skills
as
observed
by
staff
for
the
next
6
months.

pt
will
implement
healthy
personal
hygiene
practices
by
attending
community
and
peer
functions/meetings
appropriately
groomed
(showered,
clean
clothing,
teeth
brushed,
deodorant)

To
learn
basic
hygiene
and
grooming
skills,
pt
will
produce
and
commit
to
a
daily
hygiene
routine
as
reported
by
pt/observed
by
staff.

To
learn
basic
hygiene
and
grooming
skills,
pt
will
purchase/obtain
at
least
2
grooming
supplies
every
month
as
reported
by
pt
observed
by
staff.

To
learn
basic
hygiene
and
grooming
skills,
pt
will
self-initiate
attending
3
independent
living
skills
groups
each
week
as
reported
by
pt
observed
by
staff.

pt
will
independently
demonstrate
self-care
needs
by
showering
with
soap
and
shampoo
without
prompting
from
staff
at
least
_x’s
week
every
week
for
6
months
as
reported
by
pt
observed
by
staff.

pt
will
demonstrate
to
staff
_x’s
a
week
the
ability
to
prepare
well
rounded
and
balanced
meals
as
observed
by
staff.

pt
will
demonstrate
effective
independent
living
skills
by
laundering
clothes
at
least
_x’s
a
month
as
reported
by
pt/
as
observed
by
staff.

pt
will
demonstrate
an
understanding
of
Board
and
Care
rules
by
complying
with
the
rules
80%
of
the
time
during
the
first
month,
85%
of
the
time
the
next
month…,
as
reported
by
pt/
as
observed
by
staff.

pt
will
effectively
manage
symptoms
related
to
schizophrenia,
e.g.,
responding
to
internal
stimuli,
by
verbalizing
3
coping
skills
3
times
a
week
as
observed
by
staff
for
the
next
6
months.

pt
will
effectively
manage
symptoms
of
depression,
e.g.,
feelings
of
hopelessness,
worthlessness,
and
low
self-esteem,
by
verbalizing
feelings
related
to
his/her
mental
illness

pt
will
recognize,
manage,
and
cope
with
symptoms
of
depression,
e.g.,
low
self-esteem
and
feelings
of
hopelessness,
by
verbalizing
how
he/she
is
feeling
(during
Community

Meeting,
case
management
sessions,
pt)
__x/week
every
week
for
six
months
as
observed
by
staff.

pt
will
decrease
irrational
internal
stimuli
that
contribute
to
feeling
anxious
by
weekly
identifying
1
anxiety
provoking
trigger
for
the
next
6
months
as
reported
by
pt
observed
by
staff.


pt
will
develop
a
healthy
support
system
by
obtaining
and
utilizing
at
least
1
telephone
number
of
a
clean
and
sober
person
as
reported
by
pt
weekly.

pt
will
develop
a
healthy
support
system
by
making
weekly
contact
with
2
sober
support
people
as
reported
by
pt

pt
will
develop
a
healthy
support
system
by
attending
at
least
3
12-step
meetings
a
week
as
reported
by
pt
and
with
proof
of
a
completed
sign-in
sheet.

Weekly,
pt
will
reduce
risk
of
relapse
by
identifying
in
writing
at
least
10
triggers,
e.g.,
people,
places
and
things,
as
reported
by
pt/observed
by
staff.

Weekly,
pt
will
verbalize
at
least
2
statements
of
acceptance
regarding
his/her
addiction
as

pt
will
effectively
manage
impulsive
behavior
during
group
by
raising
his
hand
before
speaking
out
loud
3
times
a
week
as
observed
by
staff
for
the
next
6
mos.

pt
will
reduce
the
need
to
gain
approval
from
staff
by
identifying
and
verbalizing
at
least
one
new
coping
skill
for
increasing
emotional
independence
each
week
for
the
next
6
months
as
observed
by
staff.

Page
71
of
97
pt
Plan
Library,
Continued

pt
will
self-regulate
emotions
and/or
behaviors
by
requesting
to
speak
out
loud
in
group
_x
times
a
week
as
observed
by
staff
for
the
next
6
mos.

pt
will
increase
stress
management
skills
to
reduce
irritability
by
respectfully
verbalizing
angry
feelings
during
group
__x/week
every
week
for
six
months
as
observed
by
staff.

and
assist
assisted
decrease
for
help
in
increase
on
pt
pt's
the
the
pt
their
them
they
was
when
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Initial
Evaluation
Intake
Assessment

|
Strengths
|-


|
Reason
For
Referral
|-
Presenting
Problem:

-
History
And
Onset
Of
Presenting
Problem:


-
Developmental
And
Family
History
As
It
Relates
To
The
Presenting
Issue:


-
Current
Family
Information
As
It
Relates
To
Presenting
Issue:




|
Current
Symptoms,
Stressors
And
Behaviors
|

-


|
Medical
Necessity:
Level
Of
Functioning,
And
Functional
Capacity
|

-
[1].


Is
Client's
Impairment
In
Functional
Capacity
The
Result
Of
A
Mental/Emotional
Disturbance?
(Yes/No):


-
[2].


Does
Client's
Mental/Emotional
Disturbance
Significantly
Impair
Their
Functional
Capacity
Within
An
Important
Area
Of
Life
Functioning?
(Yes/No):


-
[3].


Does
Client's
Mental/Emotional
Disturbance
Create
For
The
Probability
Of
Significant
Deterioration
In
An
Important
Area
Of
Life
Functioning?
(Yes/No):


-
[4].


Does
Client's
Mental/Emotional
Disturbance
Create
For
The
Probability
That
The
Child/Youth
Will
Not
Progress
Developmentally
As
Individually
Appropriate?
(Yes/No/Not
Applicable):


-
[5].


Is
Client's
Mental/Emotional
Disturbance
A
Condition
Which
Specialty
Mental
Health
Services
Could
Correct
Or
Ameliorate?
(Yes/No):


-
[6].


Given
The
Nature
Of
The
Functional
Impairment
Noted
Above,
Treatment
Services
Will
Significantly
Reduce
And/Or
Prevent
Significant
Deterioration
In
Functioning,
And
Because
Of
That,
The
Following
Domain/Domains
Of
Functioning
Will
Be
Treated:

[
]
Home
And
Living
Situation

[
Yes
]
Social/Peer
And
Interpersonal
Relationships

[
]
Work/Occupation

[
]
School

[
]
Daily
Activities

[
]
Financial

[
]
Health/Medical

[
]
Family
Relationships

[
]
Legal
&
Safety

[
]
Potential
For
Exploitations

[
]
Cultural
Components

|
Psychosocial
Factors
|

-
Current
Living
Situation:
-
Educational
Attainment,
Include
Highest
Level
Of
Education
Completed:


-
Vocational
(Include
Current
Employment
Status):


-
Daily
Activities
(How
Does
Client
Spend
Their
Day
And
Are
They
Able
To
Attend
To
Activities
Of
Daily
Living?):


-
Cultural
&
Linguistic
Factors:


-
Relationships


---
Family
Relationships

------
Family
Of
Origin:


------
Immediate
Family:


---
Social/Friend
Relationships:


---
Support
Network:


-
History
Of
Trauma/Exposure
To
Trauma:


-
Legal
(Include
Conservatorship,
Probation,
Family
Court,
Litigation,
Etc.
If
Applicable):


-
Spiritual
Factors:

|
Psychiatric
History
|

[1]
-
Has
Client
Participated
In
Counseling/Psychotherapy
Services
In
The
Past?


-
If
Yes,
Please
Describe...

---
Provider:


---
Treatment
Date
Range
(Start/End
Date):


---
Therapeutic
Modalities:


---
Client's
Response
To
Treatment:


---
Psychiatric
Hospitalizations:


---
Information
From
Other
Source
Of
Clinical
Data:



[2]
-
Has
Client
Participated
In
Psychiatric/Medication
Management
Services
In
The
Past?

-
If
Yes,
Please
Describe
When,
With
Whom,
And
Experience:


-
If
Yes,
Please
Specify
Medication
Name,
Dosage,
What
The
Medication
Is
For,
And
Prescribing
Provider:


|
Current
Risks
|-
No
Risks
Present
At
Time
Of
Intake.


-
Does
Client
Have
A
History
Of
Trauma/Exposure
To
Trauma?
(Yes/No/Unknown
At
This
Time):


-
This
Writer
Rendered
Risk
Assessment
For
S/I
And
H/I;
Client
Denied,
Unable
To
Specify
Plans,
Means,
Motivation,
Intent;
Client
Described
Content
Associated
With
Future
And
Goals
Associated
With
Establishing
Positive
And
Meaningful
Interpersonal
Relationships
In
Their
Community.

|
Medical
History
|

-
Current
Physical
Condition/Illness:


-
Primary
Care
Physician
(Name,
Address,
Phone):


-
If
Child/Adolescent,
Describe
Developmental
History
And/Or
Prenatal/Perinatal
Events:

|
Medications
|

-
Is
Client
Actively
Taking
Medication
At
This
Time?


-
If
Yes,
Please
Specify...

---
Medication
Name:


---
Start
&
End
Date
Of
Medication
(Ie.,
Fall
2012
-
Present):


---
Reason
For
Use:


---
Amount/Dosage:


---
Frequency:


-
Allergies
To
Medication
Or
Adverse
Reactions?
(Must
Specify
Yes/No):


|
Substance
Use
|

-
Substance
Types
May
Include,
But
Are
Not
Limited
To:
Alcohol,
Amphetamines,
Cocaine,
Opiates,
Sedatives,
Pcp,
Hallucinogens,
Inhalants,
Marijuana,
Nicotine,
Rx
Drugs.


-
Is
Client
Actively
Using
Substances?

---
Substance
Type:


---
Onset:


---
Dosage/Amount:


---
Frequency
Of
Use:


---
Date
Of
Last
Use:

-
If
Yes,
Is
Action
Required?


-
If
Yes,
How
Is
Substance
Use
Impacting
Mental/Emotional
Health?
}

The
psychosocial
assessment
is
the
intervention.
In
addition,
the
following
information
was
reviewed,
explained,
and
signed:
Informing
Materials,
HIPAA
Privacy
Practices,
Confidentiality
and
the
Limits
of
Confidentiality,
Problem
Resolution,
Advance
Directives,
Provider
List,
Acknowledgement
of
Receipt
form
and
Cultural/Linguistic
issues
were
also
reviewed.

This
session
was
interactive
because
of
the
utilization
of
sand
tray
with
pt
to
assist
pt
in
being
able
to
provide
information.
The
psychosocial
assessment
is
the
intervention.
In
addition,
the
following
information
was
reviewed,
explained,
and
signed:
HIPAA
Privacy
Practices,
Confidentiality
and
the
Limits
of
Confidentiality,
Problem
Resolution,
Advance
Directives,
Acknowledgement
of
Receipt
form,
Cultural/Linguistic
needs
and
Provider
List.
The
following
information
was
reviewed,
explained,
and
signed

Discussed
with
pt
the
need
to
report
this
information
to
Child
Protective
Services,
and
pt
was
willing
to
make
the
report
with
this
writer’s
assistance.
This
writer
called
CPS,
and
provided
support,
encouragement
and
guidance
to
pt
as
she
provided
information
to
the
CPS
social
worker.
After
the
report
was
made,
this
writer
processed
the
experience
with
pt
regarding
making
the
report
and
attempted
to
reframe
the
experience
in
an
empowering
way.


utilized
a
structured
card
game
that
required
participants
to
maintain
focus
and
tracking.
Worked
with
pts
on
identifying
how
they
felt
internally
when
frustrated
by
the
structured
task.
Progressive
relaxation
techniques,
and
self-soothing
exercises,
and
time
outs
were
also
introduced.
These
were
utilized
to
assist
pts
in
this
focusing
activity
as
well
as
the
use
of
“time-outs”
as
warranted
and
needed.
Activities
were
utilized
to
assist
pts
in
sustaining
his/her
focus
on
activities.

Communication,
coordination,
and
referral

Monitoring
to
ensure
a
pt’s
access
to
services

Monitoring
the
pt’s
progress

Relaying
information
that
is
medically
necessary
from
pt,
therapist,
case
manager,
or
psychiatrist
to
another
person

linking
pts
to
necessary
services

consulting
with
other
necessary
professional
entities
(who
are
not
identified
as
the
pt’s
support
person/people)
when
linking
pt
to
other
necessary
services

gathering
information
that
will
benefit
pt
in
receiving
necessary
services
from
sources
(who
are
not
identified
as
the
pt’s
support
person/people)
such
as
family
members,
medical
providers,
social
workers
and
educators,

making
referrals
to
providers
for
needed
services

monitoring
the
activities
for
necessary
follow
up
(i.e.,
ensuring
that
resources
that
pt
is
accessing,
to
assist
pt
in
order
to
meeting
treatment
goals
are
assisting
pt
in
the
most
efficient
and
helpful
way)

Establishing
contacts
that
are
necessary
to
ensure
the
treatment
plan
is
effectively
implemented
and
that
progress
toward
goals
are
being
made.
Case
Management
is
NOT
skill
development,
assistance
in
daily
livi

Assessment
regarding
appropriateness
of
placement.

Needs
determination

Locating
and
securing
an
appropriate
living
environment

Pre-placement
visit(s)

Securing
housing
or
placements

Placement
and
placement
follow-up

Accessing
services
necessary
to
secure
placement.


Release
of
Information
obtained.
T

This
clinician
was
able
to
speak
to
MD
that
afternoon
to
discuss
pt’s
symptoms.
This
writer
explained
to
MD
of
Peterson
Clinic
MD
the
pt’s
physical
symptoms
and
the
need
for
special
accommodations.
MD
agrees
agreed
to
allot
extra
time
to
see
this
pt
Assisting
with
a
specific
problem
area
related
to
such
activities
as
Activities
of
Daily
Living
(ADLs)

Showing
pt
how
some
obstacle
might
be
overcome
(i.e.,
how
to
obtain
a
bus
pass
when
pt
has
difficulty
making
decisions)

Identifying
obstacles
(i.e.,
pt
wishes
to
attend
Junior
College
but
has
difficulty
getting
up
in
the
morning,
does
not
know
how
to
use
public
transportation,
and
has
not
gotten
necessary
hearing
aids)

Helping
strategize
with
pt
about
what
they
can
accomplish.
(i.e.,
prioritizing
household
chores)

Education
regarding
how
problem
behaviors
are
getting
in
the
way
of
meeting
goals

Education
about
how
symptoms/problem
behaviors
might
be
managed
(i.e.,
diet
changes,
medication)

Accompanying
a
pt
in
public
to
model
and
help
pt
practice
appropriate
behavior
in
public
(i.e.,
accompanying
a
pt
to
the
grocery
store
to
assist
pt
in
practicing
appropriate
behavior
in
the
grocery
store)

helping
significant
support
persons
to
understand
and
accept
the
pt’s
condition

involving
identified
significant
support
person/people
in
planning
of
and
implementation
of
pt
plan(s)

Sessions
with
pt’s
family
(if
they
are
identified
as
significant
support
person/people)
on
behalf
of
pt
with
the
intent
of
benefiting
pt

Family
sessions
with
the
focus
on
benefiting
the
pt,
with
the
pt
present,
are
also
included
in
Collateral.

Obtaining
information
from
an
important
person
in
pts
life

Discussing
(with
Release
of
Information)
with
an
important
person
in
pt’s
life
how
to
collaborate
and
help
pt
to
overcome
obstacles,
or
how
they
might
support
(and
not
hinder)
some
area
of
improvement
in
functioning.

due
to
recent
increase

pt
is
not
sleeping
well,
is
becoming
increasingly
manic
and
appears
to
be
hearing
voices
Will
discuss
information
with


Completed
crisis
assessment
to
determine
Danger
to
Self,
Danger
to
Others,
or
level
of
grave
disability.

focused
on
issues
of
will
teach


assist
the
pt
in
achieving
the
pt’s
goals


Symptom
Reduction
group;
Living
Skills
group;
and
providing
feedback
from
staff
in
Community
group,
Case
Management,
Medication
Support
Intervention
Starters
(depends
on
service
activity)
¾
Acknowledged
pt
¾
Assisted
pt
with
¾
Assisted
pt
to
¾
Briefed
pt/parents,
etc.
about
¾
Brainstormed
possible
solutions/ways
to
¾
Built
rapport
by
¾
Commended
pt
¾
Consulted
with

¾
Coordinated
with

¾
Cued
pt
¾
Developed
¾
Directed
pt/pt’s
attention
¾
Discussed
¾
Discussed
consequences
of
¾
Employed
positive
reinforcements
to
¾
Encouraged
pt
to
¾
Engaged
pt
in
positive
social
interaction
¾
Explored
ideas
about
¾
Facilitated…for
an
extended
period
¾
Gave
cues/prompts
to
¾
Generated
¾
Identified
¾
Implemented
¾
Informed
¾
Intervened
when
¾
Intervened
with
¾
Located
¾
Maintained
¾
Monitored

maintenance
of

¾
Monitored
pt’s

interactions
with
peers

¾
Observed
¾
Offered

¾
Offered
to
¾
Practiced

¾
Praised
¾
Prompted
pt
to
comply
with
expectations
¾
Problem
solved
¾
Prompted
pt
to

¾
Provided
frequent

¾
Redirected
¾
Reframed
¾
Reminded
¾
Reviewed

pt’s

¾
Role
modeled
¾
Set
clear

limits/boundaries
¾
Suggested
¾
Supported
¾
Used
humor
to

Assisted
pt
with

for


an
extended
period
of
time/

in
a
variety
of
settings.
¾
Assisted
pt
with

to

interact
with
others/peers

in
a

out
in
the
community.
¾
Brainstormed
with
pt

possible
alternatives
to…

describe
alternative
to
his/her
behavior
¾
pt
seemed

redirection.
¾
Role

with

______

meeting…
…to
assist
pt
with

his/her

behavioral
goals/plan.

¾
Assisted
pt
in
developing
increased

/hygiene/
personal
safety/the
usefulness
of

an
education…
¾
Engaged
pt
in
a

problem-solving
session

regarding…
¾
Upon
this
staff’s
arrival,

pt
appeared
/seemed/
to
be

in

a

…describe

the

with
a

qualifyingstatement

i.e.

bright
affect,

flat
affect,

/demeanor,

talkative,


with

description
of
specific,

Current
legal
involvement
with
law
enforcement,
probation,
or
parole

Arrest
History
(when
and
what)

Past
legal
involvement
with
law
enforcement,
probation,
or
parole

Past
or
current
involvement
with
Child
Welfare
Services
(CWS)

Involvement
with
Public
Guardian/Administrator’s
office


will

week

as
observed
by
Once

as
observed
by




develop

healthy
support
system

by


verbalizing



reduce

or

To
learn
basic
hygiene

grooming
skills

community
resources

having

Met
with


observed
by



reports

needs
approval


brainstormed
possible
solutions
ways


briefed
parents
about

comply


description


expectations

facilitated
an
extended
period

hygiene


six
months


specific


upon
arrival


variety
settings


week
every
week

an
education

an
extended
period
time

assist

assisted

describe
alternative
behavior
developing

from

guardian

increased

interact

involvement

meeting

parent

peers

personal
safety

an

assessment



attack


authorization
for
due
to

present

pt

session

Subsequent
to

supervisor

Current
medication
(prescribed
or
over-the-counter)
For
medication,
document
dosage
and
frequency.

Relevant
Prior
Medications

Medical
Issues

Allergies
(to
medication,
food,
seasonal,
etc.)

Hospitalizations

Surgeries

Illnesses

For
children,
document
developmental
history,
including
prenatal
and
perinatal
events

Appearance
(i.e.,
older
than
stated
age,
younger
than
stated
age,
disheveled,
clean,
neat,
odd
appearance,
etc)

Behavior
(i.e.,
overactive,
under
active,
fidgety,
distant,
childlike
(for
an
adult),
friendly,
impulsive,
etc.)

Attitude
(i.e.,
cooperative,
uncooperative,
evasive,
etc.)

Mannerisms
(i.e.,
gestures,
tics,
grimacing,
etc.)

Page
61
of
97
Components
of
Assessment,
Continued

Posture
(i.e.,
slumped,
relaxed,
stooped,
etc.)

Speech
(i.e.,
soft,
coherent,
incoherent,
rambling,
pressured,
etc.)

Affect
(i.e.,
appropriate,
rich,
flat,
restricted,
blunted,
etc.)

Mood
(i.e.,
euthymic,
depressed,
elevated,
etc.)

Characteristics
of
thoughts
(i.e.,
illusions,
paranoia,
grandiosity,
hallucinations,
delusions,
etc.)

Orientation
(i.e.,
person,
place,
time)

Memory
(i.e.,
remote,
recent,
immediate,
etc.)

Intellectual
functioning

Eye
Contact

Awareness
of
illness

Appetite

Sleep
(i.e.,
nightmares,
waking
frequently,
difficulty
falling
asleep,
sleeping
too
little,
sleeping
a
great
deal)

1
What
safety
issues
were
present?
2
Are
there
any
safety
issues
that
need
to
be
monitored?
3
Medical
Necessity:
What
are
the
mental
health
or
community
functions
that
are
still
not
1
pt
Intervention:
What
did
you
attempt
to
accomplish
with
the
individual?
2
If
you
modified
the
intervention;
how
did
you
modify
it
as
appropriate?
1
How
did
the
individual
react
to
the
intervention?
2
What
are
the
plans
for
continuing
to
work
with
this
pt?
2
How
do
you
see
the
pt
moving
or
not
moving
toward
the
goal?
If
very
little
or
no
progress,
explain
why.
4
What
is
the
next
step
you
are
planning
to
carry
out?

Will
present
to
supervisor
for
disposition
of
services.
Subsequent
to
authorization
for
ongoing
outpatient
mental
health
services,
pt
will
return
to
develop
pt
plan.
Total
Time:
93
Min.

ongoing
outpatient
mental
health
services,
pt
and
mother
will
return
to
develop
pt
plan.

Due
to
pt’s
severe
mental
illness,
this
writer
is
not
referring
pt
to
Sexual
Assault
and
Domestic
Violence
Center
(SADVC)
where
she
reported
she
would
feel
out
of
place.
Will
plan
to
use
cognitive
techniques
and
will
consult
with
psychiatrist
regarding
possible
medication
changes.
Will
plan
to
monitor
pt
closely
to
ensure
she
has
sufficient
support
to
prevent
decompensation.

Symptoms
as
reported
by
pt,
caregiver,
or
other
involved
party
(i.e.,
a
teacher
reporting
hyperactivity
in
the
classroom)

Behaviors
as
reported
by
pt,
caregiver,
or
other
involved
party

Frequency
of
symptoms
and
behaviors
(Be
as
specific
as
possible.
This
may
help
you
when
writing
the
pt
Plan
goals.)

Precipitating
events/stress

History
of
Trauma
or
Abuse
(physical,
sexual,
emotional).
Witnessing
Domestic
Violence
would
also
be
pertinent
information.

Other
relevant
history
(i.e.,
familial
relationship
issues)

Relevant
conditions
affecting
mental
health
(i.e.,
physical
stressors,
relationship
factors,
living
conditions,
job/employment/educational
stressors,
etc)

Medical
conditions
that
could
be
affecting
mental
health

History
of
presenting
problem
(i.e.,
when
did
the
symptoms
begin?)

If
completing
a
child’s
assessment,
also
document
the
response
of
the
caregivers
to
the
symptoms
and/or
behaviors.

agression
lack
of
skill
set
inappropriate
interaction
with
others
lack
of
support
lack
of
access
inadequate
ability
to
pt
presents
with

complaints
of

problems
with
family
inability
to
keep
employment
which
result
in

over
spending

pt
appears
denies
any
suicidal/homicidal
ideation.

pt
denies

pt
is

currently

on
unemployment
which
will
soon

pt
was
arrested
in
another
county

causing
a
disturbance

a
store.

Has
a
history
of

during
the
last

the
first
at
age
23

Met
with
pt

and
pt

to
complete
intake
paperwork.

pt
is
a
9
year
old
Caucasian
female,
presenting
with


difficulty
sleeping,


weight
loss
(Approx.
10
pounds
in
the
past
month),
and
having


great
difficulty
communicating
with
peers
or
family.
pt
answered
a
couple
of
questions
with
a
“yes”
or
“no”
answer,

pt
was
mostly

during
the
intake.

made
little
eye
contact
and

hid
her
face
behind
hair.
pt
reports
that

about
three
months
ago,

pt
began
having
a
great
deal
of

difficulty
focusing
in
class,
and

pt’s
grades
have
begun
falling.

pt
also
reports
frequent
crying
spells.

pt
denies
any
trauma
or
abuse
of
pt;

pt
shook
her
head
in
response
to
the
question.

pt
reports
that
she
and
father
are
divorced;

father
lives
out
of
state
and
has
had
little
contact
with
pt
for
several
years.

Met
with
pt
to
complete

pt
has
a
hx
of
severe
major
depressive
sx,
and

has
been
hospitalized
three
times
in
the
past
year
for
suicide
attempts.

Currently,
pt
reports

hypersomnia,

low
appetite,
difficulty
concentrating,
and

poor
memory,

reports
no
S/I
or
H/I.

She
is
currently
receiving
medication
services
from
YCADMH
and
reports
taking
her
medication
regularly.
pt
has
a
hx
of

disruptive
behaviors,

including
throwing
things
at
other
people,
fighting
with
peers
at
school,
and

being
physically
aggressive
with
younger
sister.
pt
has
been
receiving
services
through
this
agency
and
with
this
writer
for
the
past
year,
and
has
made
some
small
progress
on
goals.

pt
continues
to
be
disruptive
in
class
(e.g.,
throwing
pencils
at
classmates
while
the
teacher
is
lecturing,
not
completing
homework,
walking
out
of
class)
and
continues
to
have
difficulty
getting
along
with
younger
sister.

pt
has
been
suspended
from
school
once
in
the
past
6
months,
and
this
was
due
to
starting
a
fight
with
another
student.

reports
that
she
is
having
intrusive
thoughts
and
related
to
a

sexual
assault
she
endured

while
homeless
last
year.

She
has
not
told
anyone
about
this
assault

her
self-blaming
about
the
attack.


functional
skills

daily
living
skills

social
and
leisure
skills

grooming
and
personal
hygiene
skills

Met
with
pt


to
work
on

with
a
focus
on

skillbuilding
tasks.

The
goal
that
is
being
focused
on
today

relates
to

impulsivity.
Previous
mental
health
providers
(include
location,
provider,
date,
and
duration
of
care,
if
at
all
possible)

Past
hospitalizations
(include
location,
provider,
date,
and
duration
of
care,
if
at
all
possible)

Why
were
the
previous
services
received?

Under
what
circumstances
did
the
pt
receive
services?


Current
employment
situation/employment
history

Marital
Status

Social
Support
Network
(for
a
child
assessment,
document
caregivers).

Relevant
family
history
(abuse,
neglect,
substance
abuse
history,
mental
health
history,
chronic
illness)

For
children,
document
school
functioning.
The
assessment
form
requires
that
information
regarding
grade
and
school,
academic
ability,
achievements,
any
special
education
participation,
and
vocational
goals
must
be
documented.


clinician
was
able



speak


pt’s
symptoms


pt’s


discuss


writer
explained


any
change
of
symptoms


in
last
year

Approx
halfway
through
assessment


asking
writer

repeat
question


While
discussing
pt’s
suicidal
or
homicidal

Clinician


condition
is
deteriorating


identifying
how
they
felt
internally
when
frustrated
by


pt
asked


pt
will
consult
with


psychiatrist


reintegration


pt
proceeded

engage
successfully
in
activity
without
further

reports
taking
medication
regularly


rolled
eyes


self
blaming


session
was
interactive
because
of
utilization
of
sand
tray
with
pt

assist
pt

Symptom
Reduction
group
Living
Skills
group
providing
feedback
from

there
were
several
questions
still
needing

be
answered


tracking
Worked
with
pt
on


when


writer
pt
discussed
goals
of
increasing
appropriate

writer
informed
pt


every
week
for
#
months


every
week


#


as
observed
by


hx
of

accessing


an
extended
period
of
time


As
part
of
improving
social
skills
pt
will
improve
self
awareness
by
reporting

staff
1

assist
pt
in
achieving
pt’s
goals

by
taking

communicating


Completed
crisis
assessment

determine
Danger

Self


description
of
specific


great
difficulty


in
variety
of
settings


interventions
monkey

peers
or
family


pt
appeared
pleased
with
goals
decided
upon
pt
expressed
he
could

pt
appreciative
of
intervention
reports
drop

pt
identified
their
own
triggers


pt
is
9
year
old
Caucasian
female
presenting
with


pt
was
assessed

be
at
low
risk


pt
was
determined

be

pt
was
teary
eyed
while
answering
questions


appeared

have
difficulty
focusing

pt
was
willing

discuss

spent
some
time
processing
through
feelings


talking
over


psychosocial
assessment
is
intervention


In
addition


following
information
was

utilized


structured


card
game


required



maintain
focus

weight
loss
Approx
#
pounds
in
past
#
month


Will
present

supervisor
for
disposition
of
services


Subsequent

authorization
for

writer
assisted

pt
understands


assist
pt
with

“yes”
or
“no”

&
how

help

Accessing
services
necessary

secure
placement

Accompanying
pt
in
public

model

Affect
appropriate
rich
flat
restricted
blunted

Allergies

medication
food
seasonal

Arrest
History
when
what
Assessment
regarding
appropriateness
of
placement

At
least
twice
week
for
next
6
months
during
case
management
meetings
plan
Attitude
cooperative
uncooperative
evasive

overactive

under
active

fidgety

distant

childlike
for
an
adult

friendly

Behaviors
as
reported
by
pt

caregiver

other
involved
party
Characteristics
of
thoughts

illusions

paranoia

grandiosity

hallucinations

delusions

consulting
with
other
necessary
professional
entities

who
are
not
identified
as

Current
assessment
of
assault
risk

documentation
as

what
information

assessment
Current
assessment
of
suicidal
ideations
gestures

or
attempts

documentation
as

Discussing
with
Release
of
Information
with
an
important
person
in
pt’s
life
how

Education
about
how
symptoms
problem
behaviors
might
be
managed

Education
regarding
how
problem
behaviors
are
getting
in
way
of
meeting
goals
Establishing
contacts
are
necessary

ensure
treatment
plan
is
effectively
Family
sessions
with

focus
on
benefiting

pt
present

are
also
Financial

including
Medi
Cal
eligibility

For
children
document
developmental
history

including
prenatal

perinatal
events

For
children

document
school
functioning

assessment
form
requires

information
Frequency
of
symptoms

behaviors
Be
as
specific
as
possible

may
help
you
when
gathering
information

will
benefit
pt
in
receiving
necessary
services
from
sources
grooming

personal
hygiene
skills

Helping
strategize
with
pt
about
what
they
can
accomplish

assaultive
or
abusive
behavior

If
there
is

history
of

History
of
presenting
problem

when
did
symptoms
begin?
History
of
Trauma
or
Abuse

physical

sexual

emotional

Witnessing
Domestic
Violence
If
there
is
any
current
use
of
tobacco
or
caffeine
frequency
of
use
must
be
documented

Involvement
with
Public
Guardian
Administrator’s
office

involving
identified
significant
support
person
people
in
planning
of

implementation
Locating

making
referrals

providers
for
needed
services
tics

grimacing

Medical
conditions
could
be
affecting
mental
health
case
management
sessions

for
#

Memory

remote

immediate

monitoring
activities
for
necessary
follow
up

ensuring

resources

Monitoring
pt’s
progress
Monitoring

ensure
pt’s
access

services
Mood
euthymic
depressed
elevated

Community
group

as
observed
by
staff

pt
will
identify
barriers

week
in
Life
Skills
group

pt
will
process

explore
Orientation
person
place
time
Other
relevant
history
familial
relationship
issues
Past
hospitalizations
include
location
provider
date
duration
of
care
if
at
all
possible
Past
legal
involvement
with
law
enforcement
probation
or
parole
Past
or
current
involvement
with
Child
Welfare
Services
CWS
Past
use
of
illicit
substance

alcohol

tobacco

caffeine

abuse
of
prescription
drugs
Placement

Posture

slumped

relaxed

stooped

pt
will
decrease
irrational
internal
stimuli

contribute

feeling
anxious
by
weekly
pt
will
demonstrate
an
understanding
of
by
complying
with

rules
pt
will
demonstrate
effective
independent
living
skills
by
laundering
clothes
at
least

’s

pt
will
demonstrate

staff
’s
week
ability


prepare
well
rounded
balanced
pt
will
develop

attending
at
least
3
12
step
meetings
week

as
making
weekly
contact

#
2

sober

support
by
obtaining

utilizing
at
least
1

telephone
pt
will

effectively
manage
anxiety
related

h
persistent
mental
illness
by
sharing
h

pt
will
effectively
manage

impulsive
behavior
during
group
by
raising
hand
before
social
anxiety

at
least
3
symptoms
of

at
effectively
manage
symptoms
of

depression

e
g

feelings
of
hopelessness

pt
will
effectively
manage
symptoms
related


schizophrenia
e
g

responding

internal
pt
will
implement

healthy
personal
hygiene
practices

by
attending

community
peer
pt
will
improve
social
skills
by

one
difficulty
related


social
pt
will
increase
ability

concentrate


focus
on


daily
basis
by
demonstrating

increase

relationship
skills

social
interactions

communicating
pt
will
increase
stress
management
skills

reduce
irritability
by
respectfully
verbalizing
pt
will
independently

demonstrate
self
care
needs
by
showering
with
soap
shampoo
pt
will
recognize

manage

cope
with

symptoms
of
depression
e
g

low
self
esteem

reduce
feelings
of
anxiety
about
housing
by
verbalizing
thoughts
related

housing
pt
will
reduce

feelings
of
anxiety
around
not
being
understood
by
verbalizing
thoughts
pt
will
reduce
social
anxiety
related


persistent
mental
illness

emotional
reduce
social

withdrawal
by
actively
participating
in
available
treatments
social
pt
will
reduce
social

withdrawal
by
identifying

three
triggers
of

isolation
as
need

gain
approval

from
staff

by
identifying

verbalizing
at
least
one
pt
will
self
regulate
emotions

behaviors

by
requesting


speak
pt
will
understand

need
for
good
hygiene

by
reporting

practicing
3
healthy
personal
Referrals

other
providers
based
on

level
of
services
needed
Relaying
information

is
medically
necessary
from
pt

therapist

case
manager

or
Sessions
with
pt’s
family
if
they
are
identified
as
significant
support
person
people
Showing
pt
how
some
obstacle
might
be
overcome

Speech
soft
coherent
incoherent
rambling
pressured

Life
Skills
group
as
observed
by
staff
pt
will
identify
socially
week
Symptom
Reduction
group

pt
will

improve
relationship
skills

pt
will
identify

communicate
triggers
of
anger


learn
basic
hygiene

pt
will
produce

commit


daily
hygiene
pt
will
self
initiate
attending
3
independent
Twice

Symptom
Reduction

group

pt
will
identify
Under
what
circumstances
did
pt
receive
services?

Weekly
pt
will
reduce
risk
of
relapse
by
identifying
in
writing
at
least
10
triggers
e
g

Weekly
pt
will
verbalize
at
least
2
statements
of
acceptance
regarding
addiction
as
Weekly
in
Life
Skills
group
as
observed
by
staff
pt
will
identify
internal
barriers

With
regards

past
use
date
of
last
use
must
be
documented

0
times
day
1

How
did
individual
react

intervention?
1
pt

Intervention:

What
did
you
attempt

accomplish
with
individual?
1
What
safety
issues
were
present?
2
Are
there
any
safety
issues
need

be
monitored?
2
How
do
you
see
pt
moving
or
not
moving
toward
goal?
If
very
little
or
no
2
If
you
modified
intervention
how
did
you
modify
it
as
appropriate?
2
What
are
plans
for
continuing

work
with
pt?
3
Medical
Necessity:

What
are
mental
health
or
community
functions
are
still
not
3
times
day

Acknowledged
pt

Assisted
pt
in
developing


Assisted
pt
with


Brainstormed
possible
solutions


ways


Brainstormed
with
pt


Briefed
pt
parents
about

Built
rapport
by

Commended
pt

Complied
with
expectations


Did
not
respond

Consulted
with


Coordinated
with


Cued
pt

Directed
pt
pt’s
attention

Discussed
consequences
of

Engaged
pt
in


Engaged
pt
in
positive
social
interaction

Facilitated…for
an
extended
period

Intervened
with

Monitored
pt’s


Prompted
pt



Prompted
pt

comply
with
expectations

pt
modified
behavior

pt
seemed


pt’s
behavior
mimicked
paralleled
staff’s

Upon
staff’s
arrival


Used
humor



Was
able

de
escalate
4
What
is
next
step
you
are
planning

carry
out?

6
months
was

80%
of
time
during
first
month
85%
of
time
next
month…
as
reported
by
pt


hx
of


monkey

ability

complete
projects
during
Creative
Arts
groups
2
times
per
week
for
next
6
Accompanying
pt

grocery
store

assist
pt
in
practicing
acknowledged
pt
success

Activities
were
utilized

assist
pt
in
activity

addition
following
information
was
reviewed
explained
signed:
HIPAA
Privacy
Addressed
pt’s
concerns

After
report
was
made

agreed
it
was
empowering
she
was
doing
right
thing

protect
child

all
possible
angry
feelings
during
group
week
every
week
for
six
months
as
observed
by
staff

another
student

answer

anxiety
anger

anyone

appearance

appears

be
hearing
voices
as
well
as

assault

assistance
in
daily
livi
assisted
pt

Assisted
pt
in

assisted
pt
in
developing
insight
into
Assisting
with
specific
problem
area
related

such
activities
as
Activities
of
Daily
attempted

reframe
experience
in
an
empowering
way

been
receiving
services
through
agency
with
writer
for
past
year
has
made
began

being
physically
aggressive
with
younger
sister
pt
has
but
has
difficulty

by
amount
of
support
he
received
from
group
pt
quickly
identified
two
triggers:
Case
Management
is
NOT
skill
development

changes
Will
plan

monitor
pt
closely

ensure
she
has
sufficient
support

prevent
chronic
illness
Clinical
Guide—Updated
by
Quality
Management
on
2
19
2010
clinician’s
statement
she

coached
pt
on

collaborate
help
pt

overcome
obstacles
or
how
they
might
support
not
community
family
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pt
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office
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plan

continues

have
difficulty

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skills
for
anxiety
such
as
writing
going
for
walk
talking

friend
or
painting

coping
skills
for
managing
auditory
hallucinations
for
next
six
months

create
plan

avoid
triggering
situations

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legal
involvement
with
law
enforcement
probation
or
parole
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medication
prescribed
or
over
counter
For
medication


dosage

Danger

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describe
alternative

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development
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group
pt
pt
will
identify
verbalize
barriers

focusing

did
not
provoke
attack

diet
changes

difficulty
focusing
in
class

Directives
Acknowledgement
of
Receipt
form
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Linguistic
needs
Provider
List

Discussed
with
pt
need

report
information

Child
Protective
Services

does
not
know
how

use
public
transportation

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Violence
Center
SADVC
where
she
reported
she
would
feel
out
of
place
Will
plan

due


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pt’s
severe
mental
illness
writer
is
not
referring
pt

Sexual
Assault

during
most
of
session
but
appeared
calm
prior

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today

during
last

educated
pt

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pt
about
medications
how
they
can
reduce
symptoms
of
empowered

decrease
overall
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encouragement

endured

entirely
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of

experiencing
nightmare
father
lives
out
of
state
has
had
feelings
of
feelings
of
hopelessness
by
verbalizing
how
he
she
is
feeling
during
Community
fighting
with
peers
at
school

focusing

for
next
6
months

functions
meetings
appropriately
groomed
showered
clean
clothing
teeth
brushed
deodorant
gestures
or
attempts
information
must
be
documented

getting
along

getting
up
in
morning

going

sleep
tonight

guidance

Has
history
of

has
been
hospitalized

has
cognitive
ability

learn
new
coping
skills
gain
new
insights
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not
gotten
has
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of
humor
help
pt
practice
appropriate
behavior
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help
them

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pt
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on
progress
they
have
made
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far
on

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support
persons

understand
accept
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condition
herself


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face
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hair

hinder
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of
improvement
in
functioning

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of
suicidal
ideations
gestures
or
attempts
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there
is
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of
ideations

homeless

honestly
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maintaining
medication
compliance
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with
support
from
household
chores
how

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pass
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is
discouraged
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however
she
was
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hygiene
skills
as
observed
by
staff
for
next
6
months

hyperactivity
in
classroom
identify
barriers

participating
in
group
for
next
six
months

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provoking
trigger
for
next
6
months
as
reported
by
pt
observed
by
if
he
feels
implemented

impulsive

in
anxiety
level

in
being
able

provide
information
psychosocial
assessment
is
intervention
In
in
planning

in
session
in
past
year

inability

keep
employment
included
in
Collateral

increasing
assertive
behaviors
such
as
speaking
up
for
herself

help
pt
feel
more
indicate

indicated
she
very
much
wanted

“get
better”
have
less
anxiety
She
was
tearful
interact
with
others
peers

interactions
twice
week
for
next
6
months
as
observed
by
staff

interrupting

into
group

intrusive

intrusive
thoughts

irritability
surface
during
interactions
at
least
2
times
week
as
observed
by
staff
for

is
accessing

assist
pt
in
order

meeting
treatment
goals
are
assisting
pt
in

is
becoming
increasingly
manic

last
year

learn


least
once
week
as
observed
by
staff
for
next
6
months

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pt
in
practicing

level
of
grave
disability

level
of
involvement
from
pt
parent
guardian
or
linking
pts

necessary
services
little
contact
with
pt
for
several
years

living
conditions
job
employment
educational
stressors

living
skills
groups
each
week
as
reported
by
pt
observed
by
staff

MD
agrees
agreed

allot
extra
time

see

meals
as
observed
by
staff

medication
medication
compliance

modeled
appropriate
communication
skills

pt

month
as
reported
by
pt
as
observed
by
staff

months
as
observed
by
staff

most
efficient
helpful
way
mother
in
waiting
area

motivated
for
therapy
necessary
hearing
aids
needed

negative
1
positive
social
interaction
2
times
week
for
next
6
months

new
coping
skill
for
increasing
emotional
independence
each
week
for
next
6
months
as
new
seat

next
6
mos

not

not
completing
homework

number
of
clean
sober
person
as
reported
by
pt
weekly

observed
by
staff

observed
by
staff
week
every
week
for
six
months

of
pt
plans
on
behalf
of
pt
with
intent
of
benefiting
pt
on
questions
as
evidenced
by
frequent
hesitation
in
answering
questions
apologizing

ongoing
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mental
health
services
pt
mother
will
return

develop
pt
plan

ongoing
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mental
health
services
pt
will
return

develop
pt
plan

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paperwork

be
completed
annually:
out
in

people
places
things
as
reported
by
pt
observed
by
staff

physical
symptoms

placement
follow
up
pointed


possible
alternatives


possibly
other
children
in
future
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took
lead
on
formulating
goals

practiced
assertive
communication
skills

increase
interpersonal
effectiveness
practiced
effective
communication
skills

assist
pt
in
decreasing
their
Practices
Confidentiality
Limits
of
Confidentiality
Problem
Resolution
Advance
Present
use
of
illicit
substances
alcohol
tobacco
caffeine
abuse
of
prescription
drugs
Previous
mental
health
providers
include
location
provider
date
duration
of
care
if
at
prioritizing
Progressive
relaxation
techniques

provided
information

CPS
social
worker

provided
support

Provider
List
Acknowledgement
of
Receipt
form
Cultural
Linguistic
issues
were
also
psychiatrist

another
person

pt
agreed

utilize
peer
support

pt
also
reports
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spells

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answered

pt
answered
questions
with
one
word
answers

pt
began
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great
deal
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by
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time
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continues

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class

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relief
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of

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pt
is
currently

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Plan
Library
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reported
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intimidated
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at
first
regarding
report
however
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reported
he
was
surprised
pt
reported
she
felt
better

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reports
pt
reports

pt
reports
she
father
are
divorced

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setbacks

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shook
head
in
response

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skipping
out
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office

join

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able

independently
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was
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then
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by
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staff
placed
in
5150
hold

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was
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was
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with

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attend

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begun
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framed
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regarding
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sheet

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or
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pt
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at
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as
observed
by
staff
for
next
6
months

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current
coping
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risks
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in
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life:
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as
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by
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in
past

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an
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environment
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exercises

session
is
an
assessment

severe
major
depressive
sx

sexual
assault

she

she
is

She
is
currently

signed

significant
support
persons:
signs
of

sleeping
well

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small
progress
on
goals

speaking
out
loud
3
times
week
as
observed
by
staff
for
next
6
mos

staff

starting
fight

still
needs
approval
for
services

stimuli
by
verbalizing
3
coping
skills
3
times
week
as
observed
by
staff
for
next
6
months

strategically
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structured
task

suicide
attempts

supplies
every
month
as
reported
by
pt
observed
by
staff

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focus
on
activities

symptoms
or
behaviors

Symptoms
as
reported
by
pt
caregiver
or
other
involved
party
teacher
reporting
symptoms
of
anxiety
appropriate
coping
techniques
3
times
week
for
next
6
months

taking
medication
unprompted
by
staff
for
next
six
months


progress
toward
goals
are
being
made


attack


attack
In
addition
writer
explained


continuation
of
voices
despite


following
information
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goal
is
being
focused
on
today


need
for
special
accommodations

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their
priorities
them

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pt

these
feelings
week
during
process
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as
observed
by
staff
for
six
months

These
were
utilized

assist
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in

thoughts
pt
denied
any
currently
verbally
contracted
for
safety
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with
their
triggers

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times

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outs
times
week
as
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staff
for
next
6
mos


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least
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as
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by
staff
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next
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triggers
of
paranoid
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or
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for
next
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months

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week
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Socialization
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staff
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was
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cause
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techniques

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techniques

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point
of
view
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walking
out
of
class

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fidgeting
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chair

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also
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what
information
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when
in
crisis
when
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difficulty
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decisions
where
she
could
be
more
focused
less
distracted
After
time
out
while

who
are
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identified
as
pt’s
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person
people
such
as
family
members

with
focus
on

with
pt

without
prompting
from
staff
at
least
’s
week
every
week
for
6
months
as
reported
by
pt
worked
with
pt

worthlessness
low
self
esteem
by
verbalizing
feelings
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illness
writer
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observed
writer
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experience
with
pt
writer’s
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pt
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READY:

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Referrals
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talking
to
friend
or
painting

create
plan
to
avoid
triggering
situations

Danger
to
Others

describe
alternative
to
behavior
development
individual
group
pt
pt
will
identify
verbalize
barriers
to
focusing

Discussed
with
pt
need
to
report
information
to
Child
Protective
Services

documentation
as
to
documentation
as
to
what
information

does
not
know
how
to
use
public
transportation

Domestic
Violence
Center
SADVC
where
she
reported
she
would
feel
out
of
place
Will
plan
to
Due
to
pt
severe
mental
illness
writer
is
not
referring
pt
to
Sexual
Assault

during
most
of
session
but
appeared
calm
prior
to
leaving
today

effectively
manage
anxiety
related
to
h
persistent
mental
illness
by
sharing
h

empowered
to
decrease
overall
anxiety

going
to
sleep
tonight

has
cognitive
ability
to
learn
new
coping
skills
gain
new
insights
helping
significant
support
persons
to
understand
accept
pt
condition
herself
to

honestly
commit
to
maintaining
medication
compliance
sobriety
with
support
from
hopes
to
how
to
obtain
bus
pass
identify
barriers
to
participating
in
group
for
next
six
months

in
being
able
to
provide
information
psychosocial
assessment
is
intervention
In
increasing
assertive
behaviors
such
as
speaking
up
for
herself
to
help
pt
feel
more
indicated
she
very
much
wanted
to
“get
better”
have
less
anxiety
She
was
tearful
is
accessing
to
assist
pt
in
order
to
meeting
treatment
goals
are
assisting
pt
in

learn
to

MD
agrees
agreed
to
allot
extra
time
to
see

modeled
appropriate
communication
skills
to
pt

need
to
gain
approval

ongoing
outpatient
mental
health
services
pt
mother
will
return
to
develop
pt
plan

ongoing
outpatient
mental
health
services
pt
will
return
to
develop
pt
plan

plans
to
pointed
to

practiced
assertive
communication
skills
to
increase
interpersonal
effectiveness
practiced
effective
communication
skills
to
assist
pt
in
decreasing
their
provided
information
to
CPS
social
worker

pt
agreed
to
utilize
peer
support

pt
continues
to
be
disruptive
in
class

pt
expressed
commitment
to
maintaining
sobriety

pt
shook
head
in
response
to
question

pt
skipping
out
of
office
to
join

pt
was
able
to
independently
identify
pt
was
unable
to
pt
was
willing
to
make
report
with

pt
will
identify
barriers
to
pt
wishes
to
attend

pt
grades
have
begun
falling

pt
support
person
people
when
linking
pt
to
other
necessary
services
reduce
feelings
of
anxiety
about
housing
by
verbalizing
thoughts
related
to
housing
related
to

Responded
to

responding
to
internal
then
pointed
to
an
elephant

These
were
utilized
to
assist
pts
in

to
call
clinician

to
complete

to
complete
intake
paperwork

to
decrease

to
help

to
identify

to
increase
pt
motivation
to
change
To
learn
basic
hygiene
grooming
skills
pt
will
purchase
obtain
at
least
2
grooming
to
mother
to
indicate
elephant
to
pt
as
she

Used
empathy
to
understand

used
open
ended
questions
to
explore
pt
Utilized
cognitive
tactics
to
help
pt
understand
she
was
victim
did
not
cause
Validated
pt
point
of
view
feelings

was
able
to
who
are
not
identified
as
pt
support
person
people
such
as
family
members

without
prompting
from
staff
at
leastweek
every
week
for
6
months
as
reported
by
pt
worthlessness
low
self
esteem
by
verbalizing
feelings
related
to
mental
illness
writer
assistance




pt’s
symptoms







that
afternoon




the
pt’s


any
change
of
symptoms
in
the
last
year


Approx

halfway
through
the
assessment




asking


writer
to
repeat
the
question

While
discussing
pt’s
suicidal
or
homicidal


Clinician





condition
is
deteriorating




identifying
how
they
felt
internally
when
frustrated
by
the


pt
asked
“how
much
longer
is


thing
going
to
take?”





pt
will
consult
with
psychiatrist
regarding


reintegration

pt
proceeded
to
engage
successfully
in
the
activity
without
further


reports
taking


medication
regularly



rolled


eyes



session
was
interactive
because
of
the
utilization
of
sand
tray
with
pt
to
assist
pt


Symptom
Reduction
group

Living
Skills
group



providing
feedback
from


tracking

Worked
with
pt
on



when





writer


pt
discussed
the
goals
of
increasing
appropriate


writer
informed
pt
that



x
week
every
week
for
six
months
as
observed
by
staff



x
week
every
week
for
six
months
as
observed
by
staff




space


a
hx
of

As
part
of
improving
social
skills

pt
will
improve
self
awareness
by
reporting
to
staff
1

demeanor



description
of
specific



difficulty
sleeping



in
a
variety
of
settings


peers





pt
appeared
pleased
with
the
goals
decided
upon

pt
expressed
that
he
could

pt
appreciative
of
the
intervention


reports
a
drop

pt
identified
their
own
triggers



pt
is
a
9
year
old
Caucasian
female

presenting
with


pt
was
teary
eyed
while
answering
questions



appeared
to
have
difficulty
focusing

Release
of
Information
obtained

T

spent
some
time
processing
through
feelings



spiritual
beliefs

family
support

motivation

intelligence


good

talking
over




The
psychosocial
assessment
is
the
intervention

In
addition

the
following
information
was

utilized
a
structured
card
game
that
required


to
maintain
focus

weight
loss
Approx

10
pounds
in
the
past
month



having


Will
present
to
supervisor
for
disposition
of
services

Subsequent
to
authorization
for

pt
understands



Accessing
services
necessary
to
secure
placement


Accompanying
a
pt
in
public
to
model



Affect


appropriate

rich

flat

restricted

blunted




Allergies
to
medication

food

seasonal




Arrest
History
when


what
At
least
twice
a
week
for
the
next
6
months
during
case
management
meetings

plan
Attitude


cooperative

uncooperative

evasive




Behavior


overactive

under
active

fidgety

distant

childlike
for
an
adult

friendly

Behaviors
as
reported
by
pt

caregiver

or
other
involved
party
Characteristics
of
thoughts


illusions

paranoia

grandiosity

hallucinations

delusions

consulting
with
other
necessary
professional
entities
who
are
not
identified
as
the
Current
assessment
of
assault
risk


documentation
as
to
what
information
that
assessment
Current
assessment
of
suicidal
ideations

gestures



or
attempts


documentation
as
to
Discussing
with
Release
of
Information
with
an
important
person
in
pt’s
life
how
to
Education
about
how
symptoms
problem
behaviors
might
be
managed



Education
regarding
how
problem
behaviors
are
getting
in
the
way
of
meeting
goals
Family
sessions
with
the
focus
on
benefiting
the
pt

with
the
pt
present

are
also
Financial

including
Medi
Cal
eligibility

For
children

document
developmental
history

including
prenatal


perinatal
events

For
children

document
school
functioning

The
assessment
form
requires
that
information
Frequency
of
symptoms


behaviors
Be
as
specific
as
possible



may
help
you
when
gathering
information
that
will
benefit
pt
in
receiving
necessary
services
from
sources
grooming


personal
hygiene
skills

Helping
strategize
with
pt
about
what
they
can
accomplish




History
of
assaultive
or
abusive
behavior
If
there
is
a
history
of


behavior

the
History
of
presenting
problem


when
did
the
symptoms
begin?
History
of
Trauma
or
Abuse
physical

sexual

emotional

Witnessing
Domestic
Violence
Identifying
obstacles



If
completing
a
child’s
assessment

also
document
the
response
of
the
caregivers
to
the
If
there
is
any
current
use
of
tobacco
or
caffeine

frequency
of
use
must
be
documented

involving
identified
significant
support
person
people
in
planning
of


implementation
Locating



making
referrals
to
providers
for
needed
services
Mannerisms


gestures

tics

grimacing





Meeting

case
management
sessions

pt


x
week
every
week
for
six
months
as
observed
by
Memory


remote

recent

immediate




monitoring
the
activities
for
necessary
follow
up


ensuring
that
resources
that
pt
Monitoring
the
pt’s
progress
Monitoring
to
ensure
a
pt’s
access
to
services
Mood


euthymic

depressed

elevated




Once
a
week
in
Community
group


as
observed
by
staff

the
pt
will
identify
barriers
to
Once
a
week
in
Life
Skills
group


as
observed
by
staff

the
pt
will
process


explore
Orientation


person

place

time
Other
relevant
history


familial
relationship
issues
Past
hospitalizations
include
location

provider

date



duration
of
care

if
at
all
possible
Past
legal
involvement
with
law
enforcement

probation

or
parole
Past
use
of
illicit
substance

alcohol

tobacco

caffeine



abuse
of
prescription
drugs
Placement



Posture


slumped

relaxed

stooped




Presenting
problem

including
the
current
symptoms


relevant
conditions
affecting
mental
pt
will
decrease
irrational
internal
stimuli
that
contribute
to
feeling
anxious
by
weekly
pt
will
demonstrate
an
understanding
of
Board


Care
rules
by
complying
with
the
rules
pt
will
demonstrate
effective
independent
living
skills
by
laundering
clothes
at
least

x’s
a
pt
will
demonstrate
to
staff

x’s
a
week
the
ability
to
prepare
well
rounded


balanced
pt
will
develop
a
healthy
support
system
by
attending
at
least
3
12
step
meetings
a
week
as
pt
will
develop
a
healthy
support
system
by
making
weekly
contact
with
2
sober
support
pt
will
develop
a
healthy
support
system
by
obtaining


utilizing
at
least
1
telephone
pt
will
effectively
manage
anxiety
related
to
h


persistent
mental
illness
by
sharing
h


pt
will
effectively
manage
impulsive
behavior
during
group
by
raising


hand
before
pt
will
effectively
manage
social
anxiety
by
verbalizing
at
least
3
symptoms
of
anxiety
at
pt
will
effectively
manage
symptoms
of
depression

e
g


feelings
of
hopelessness

pt
will
effectively
manage
symptoms
related
to
schizophrenia

e
g


responding
to
internal
pt
will
implement
healthy
personal
hygiene
practices
by
attending
community


peer
pt
will
improve
social
skills
by
identifying


verbalizing
one
difficulty
related
to


social
pt
will
increase


ability
to
concentrate


focus
on
a
daily
basis
by
demonstrating
the
pt
will
increase
relationship
skills
by
identifying
two
social
interactions


communicating
pt
will
increase
stress
management
skills
to
reduce
irritability
by
respectfully
verbalizing
pt
will
independently
demonstrate
self
care
needs
by
showering
with
soap


shampoo
pt
will
recognize

manage



cope
with
symptoms
of
depression

e
g


low
self
esteem


pt
will
reduce
feelings
of
anxiety
about
housing
by
verbalizing
thoughts
related
to
housing
pt
will
reduce
feelings
of
anxiety
around
not
being
understood
by
verbalizing
thoughts
pt
will
reduce
social
anxiety
related
to


persistent
mental
illness
by
identifying
emotional
pt
will
reduce
social
withdrawal
by
actively
participating
in
available
treatments
social
pt
will
reduce
social
withdrawal
by
identifying


verbalizing
three
triggers
of
isolation
as
pt
will
reduce
the
need
to
gain
approval
from
staff
by
identifying


verbalizing
at
least
one
pt
will
self
regulate
emotions


or
behaviors
by
requesting
to
speak
out
loud
in
group

x
pt
will
understand
the
need
for
good
hygiene
by
reporting


practicing
3
healthy
personal
Referrals
to
other
providers
based
on
the
level
of
services
needed
Relaying
information
that
is
medically
necessary
from
pt

therapist

case
manager

or
Relevant
conditions
affecting
mental
health


physical
stressors

relationship
factors

Relevant
family
history
abuse

neglect

substance
abuse
history

mental
health
history

Showing
pt
how
some
obstacle
might
be
overcome



Sleep


nightmares

waking
frequently

difficulty
falling
asleep

sleeping
too
little

social


leisure
skills
Social
Support
Network
for
a
child
assessment

document
caregivers

Speech


soft

coherent

incoherent

rambling

pressured




Three
times
a
week
in
Life
Skills
group


as
observed
by
staff

the
pt
will
identify
socially
Three
times
a
week
in
Symptom
Reduction
group


as
observed
by
staff

the
pt
will
To
improve
relationship
skills

pt
will
identify


communicate
triggers
of
anger


To
learn
basic
hygiene


grooming
skills

pt
will
produce


commit
to
a
daily
hygiene
To
learn
basic
hygiene


grooming
skills

pt
will
self
initiate
attending
3
independent
Twice
a
week
in
Symptom
Reduction
group


as
observed
by
staff

the
pt
will
identify
Under
what
circumstances
did
the
pt
receive
services?

Weekly

pt
will
reduce
risk
of
relapse
by
identifying
in
writing
at
least
10
triggers

e
g


Weekly

pt
will
verbalize
at
least
2
statements
of
acceptance
regarding




addiction
as
Weekly
in
Life
Skills
group


as
observed
by
staff

the
pt
will
identify
internal
barriers
to
Why
were
the
previous
services
received?
With
regards
to
past
use

date
of
last
use
must
be
documented


1

How
did
the
individual
react
to
the
intervention?
1

pt
Intervention:
What
did
you
attempt
to
accomplish
with
the
individual?
1

What
safety
issues
were
present?
2

Are
there
any
safety
issues
that
need
to
be
monitored?
2

How
do
you
see
the
pt
moving
or
not
moving
toward
the
goal?
If
very
little
or
no
2

If
you
modified
the
intervention

how
did
you
modify
it
as
appropriate?
2

What
are
the
plans
for
continuing
to
work
with


pt?
3

Medical
Necessity:
What
are
the
mental
health
or
community
functions
that
are
still
not
¾
Briefed
pt
parents




about
¾
Directed
pt
pt’s
attention
¾
pt
modified




behavior
¾
pt’s
behavior
mimicked
paralleled
staff’s
¾
Upon


staff’s
arrival


4

What
is
the
next
step
you
are
planning
to
carry
out?

6
months





was

80%
of
the
time
during
the
first
month

85%
of
the
time
the
next
month…

as
reported
by
pt

a
hx
of

a
monkey



a
store


ability
to
complete


projects
during
Creative
Arts
groups
2
times
per
week
for
the
next
6
about



about
three
months
ago


Accompanying
a
pt
to
the
grocery
store
to
assist
pt
in
practicing
addition

the
following
information
was
reviewed

explained



signed:
HIPAA
Privacy
After
the
report
was
made




agreed
that
it
was
empowering


that
she
was
doing
the
right
thing
to
protect


child


angry
feelings
during
group


x
week
every
week
for
six
months
as
observed
by
staff


another
student


answer


anxiety

anger



appearance



Appearance


older
than
stated
age

younger
than
stated
age

disheveled

clean

neat

odd
appropriate
behavior
in
the
grocery
store

as
well
as
the
Assisted
pt
in





attempted
to
reframe
the
experience
in
an
empowering
way


been
receiving
services
through


agency


with


writer
for
the
past
year



has
made
behavioral
goals
plan


being
physically
aggressive
with
younger
sister

pt
has
boredom


phone
calls
from


mother


bright
affect


by
the
amount
of
support
he
received
from
the
group

pt
quickly
identified
two
triggers:
Case
Management
is
NOT
skill
development


CBT

DBT

stress
reduction
techniques
changes

Will
plan
to
monitor
pt
closely
to
ensure
she
has
sufficient
support
to
prevent
chasing
the
elephant
around
the
sand
tray


Clarified


sought
clarification

clinician’s
statement
that
she

collaborate


help
pt
to
overcome
obstacles

or
how
they
might
support


not
Communication

coordination



referral
community

family




agency

pt
signed
completed
treatment
plan


community
resources


completing
daily
weekly
chores
for
the
next
six
months

Components
of
Assessment

Continued
Confidentiality


the
Limits
of
Confidentiality

Problem
Resolution

Advance
Directives

Confronted
pt
about





confused



responding
to
internal
stimuli
conservatorship’s
office
in
development
of
the
treatment
plan


coping
skills
for
anxiety
such
as

writing

going
for
a
walk

talking
to
a
friend

or
painting


coping
skills
for
managing
auditory
hallucinations
for
the
next
six
months

create
a
plan
to
avoid
triggering
situations


Current
legal
involvement
with
law
enforcement

probation

or
parole
Current
medication
prescribed
or
over
the
counter
For
medication

document
dosage


Currently


Danger
to
Others


decompensation


denies
any
suicidal
homicidal
ideation


describe
alternative
to




behavior
development

individual

group

pt

pt
will
identify


verbalize
barriers
to
focusing


did
not
provoke
the
attack


difficulty
concentrating


difficulty
focusing
in
class




Directives

Acknowledgement
of
Receipt
form

Cultural
Linguistic
needs


Provider
List

Discussed
with
pt
the
need
to
report


information
to
Child
Protective
Services



disruption


disruptive
behaviors


does
not
know
how
to
use
public
transportation




Domestic
Violence
Center
SADVC
where
she
reported
she
would
feel
out
of
place

Will
plan
to
Due
to
pt’s
severe
mental
illness



writer
is
not
referring
pt
to
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verbally
throughout
total
min
paranoid
hypomanic
episodes
twice
a
week
socializati
morning
does
know
transportat
gotten
this
arrival
“timeouts”
warranted
used
empathy
open
ended
tactics
victim
cause
mindfulness
interviewing
validated
point
view
wants
watching
movies
introduced
which
result
soon
homeless
prompting
format
jewellery
worthlessness
pertinent
writing
plan
pt
understands
this
session
is
an
assessment
and
still
needs
approval
for
services.
During
intake,
pt
answered
questions
with
one
word
answers,
and
was
fidgeting
frequently
in
her
chair.
Approx.
halfway
through
the
assessment,
pt
asked
“how
much
longer
is
this
thing
going
to
take?”
and
rolled
her
eyes
when
this
writer
informed
pt
that
there
were
several
questions
still
needing
to
be
answered.

pt
understands
this
session
is
an
assessment
and
still
needs
approval
for
services.
pt
remained
non
verbal,
but
pointed
to
a
monkey
and
then
herself
to
indicate
the
monkey
represented
her,
and
then
pointed
to
an
elephant
and
to
mother
to
indicate
that
elephant
represented
mother.
pt
then
spent
the
majority
of
the
time
in
the
intake
showing
the
monkey
chasing
the
elephant
around
the
sand
tray.


pt
was
teary
eyed
while
answering
questions,
and
appeared
to
have
difficulty
focusing
on
the
questions,
as
evidenced
by
her
frequent
hesitation
in
answering
questions,
apologizing,
and
asking
this
writer
to
repeat
the
question.
While
discussing
pt’s
suicidal
or
homicidal
thoughts,
pt
denied
any
currently
and
verbally
contracted
for
safety

pt
appeared
pleased
with
the
goals
decided
upon.
pt
expressed
that
he
could
honestly
commit
to
maintaining
medication
compliance
and
sobriety
with
support
from
community,
family
and
this
agency.
pt
signed
completed
treatment
plan.

This
writer
and
pt
discussed
the
goals
of
increasing
appropriate
coping
skills
for
anxiety
(such
as,
writing,
going
for
a
walk,
talking
to
a
friend,
or
painting)
and
increasing
assertive
behaviors
(such
as
speaking
up
for
herself)
to
help
pt
feel
more
empowered
and
to
decrease
overall
anxiety.

pt
reported
feeling
intimidated
and
fearful
at
first
regarding
the
report,
however
she
agreed
that
it
was
empowering
and
that
she
was
doing
the
right
thing
to
protect
her
child
and
possibly
other
children
in
the
future.
pt
took
the
lead
on
formulating
her
goals,
and
indicated
that
she
very
much
wanted
to
“get
better”
and
have
less
anxiety.
She
was
tearful
during
most
of
the
session,
but
appeared
calm
prior
to
leaving
today.

Utilized
cognitive
tactics
to
help
pt
understand
that
she
was
the
victim
and
did
not
cause
the
attack.
In
addition,
this
writer
explained
Post
Traumatic
Stress
Disorder
(PTSD)
manifestation.

pt
expressed
that
she
felt
some
relief
in
discussing
the
attack,
however
she
was
not
entirely
trusting
of
clinician’s
statement
that
she
did
not
provoke
the
attack.
pt
is
fearful
of
going
to
sleep
tonight
and
experiencing
a
nightmare
pt
reported
that
she
felt
better,
and
this
writer
observed
pt
skipping
out
of
the
office
to
join
her
mother
in
the
waiting
area.


pt
identified
their
own
triggers,
spent
some
time
processing
through
feelings
and
thoughts
associated
with
their
triggers,
and,
utilizing
cognitive
behavioral
techniques,
began
to
create
a
plan
to
avoid
triggering
situations.

pt
expressed
a
commitment
to
maintaining
sobriety,
however,
pt
is
discouraged
by
the
continuation
of
voices
despite
his
medication
compliance.
pt
reported
he
was
surprised
by
the
amount
of
support
he
received
from
the
group.
pt
quickly
identified
two
triggers:
boredom
and
phone
calls
from
his
mother.

pt
agreed
to
utilize
peer
support,
community
resources,
or
to
call
this
clinician
if
he
feels
his
condition
is
deteriorating.
Clinician
and
pt
will
consult
with
psychiatrist
regarding
voices.

pt
was
initially
disruptive
and
intrusive;
interrupting
both
presenters
and
violating
other
participants’
space
by
taking
away
their
cards
and
talking
over
her
peers.
This
writer
assisted
pt
by
initiating
a
time-out,
then
reintegrating
pt
into
the
group
by
strategically
helping
pt
select
a
new
seat
where
she
could
be
more
focused
and
less
distracted.
After
the
time-out
and
reintegration,
pt
proceeded
to
engage
successfully
in
the
activity
without
further
disruption.


pt
appreciative
of
the
intervention
and
reports
a
drop
in
anxiety
level.
appeared
disheveled,
confused,
and
responding
to
internal
stimuli
pt
was
medically
cleared
then
evaluated
by
crisis
staff
and
placed
in
a
5150
hold

¾
pt’s
behavior
mimicked/paralleled
staff’s
¾
pt
modified
his/her
behavior
¾
Responded
age-appropriately
¾
Was
able
to
de-escalate
Did
you
spend
time
talking
to
the
pt
about
how
they’re
doing,
why
they’re
cancelling,
etc?
That
time
would
be
billable,
particularly
if
you’re
working
on
something
like
importance
of
maintaining
scheduled
appointments
for
treatment
or
working
on
treatment
planning
for
future
sessions.

Is
it
possible
to
move
a
later
pt
into
an
earlier
spot
and
possibly
reschedule
this
pt
for
later
in
the
week?
That
will
help
increase
your
billing
as
well.

If
you
still
have
time
leftover,
try
to
contact
collateral
or
case
management
supports
on
behalf
of
the
pt.
has
cognitive
ability
to
learn
new
coping
skills
and
gain
new
insights
significant
support
person(s):

spiritual
beliefs,
family
support,
motivation,
intelligence
and
good
Present
use
of
illicit
substances,
alcohol,
tobacco,
caffeine,
and
abuse
of
prescription
drugs

Past
use
of
illicit
substance,
alcohol,
tobacco,
caffeine,
and
abuse
of
prescription
drugs

If
there
is
any
current
use
of
tobacco
or
caffeine,
frequency
of
use
must
be
documented.

With
regards
to
past
use,
date
of
last
use
must
be
documented.

History
of
suicidal
ideations,
gestures
and/or
attempts
(If
there
is
a
history
of
ideations,
gestures,
and/or
attempts,
this
information
must
be
documented).

Current
assessment
of
suicidal
ideations,
gestures,
and/or
attempts
and
documentation
as
to
what
information
that
assessment
has
yielded.

History
of
assaultive
or
abusive
behavior
(If
there
is
a
history
of
this
behavior,
the
information
must
be
documented.)

Current
assessment
of
assault
risk
and
documentation
as
to
what
information
that
assessment
has
yielded.

level
of
involvement
from
the
pt,
parent/guardian,
and/or
conservatorship’s
office
in
development
of
the
treatment
plan.

untitled
project
3.bbprojectd:
kelliclarktherapy.bbprojectsettings
project.bbprojectdata
Scratchpad.txt
Unix
Worksheet.worksheet
symptoms
related

anxiety
related
her
persistent
mental
illness
by
sharing
h
he
appeared
pleased
the
goals
decided
upon
expressed
that
he
coul
appreciative
of
the
intervention
reports

drop?
at
least
1

at
least
3
by
obtaining
decrease
irrational
internal
stimuli
that
contribute
feeling
anxious
by
week
demonstrate

understanding
of
rules
by
complying
the
rule
demonstrate
effective
independent
living
skills
by
laundering
clothes
at
least
x

demonstrate
staff
x

week
the
ability
prepare
well
rounded
balance
develop

healthy
support
system
develop

healthy
support
system
by
effectively
manage
identified

triggers

spent
some
time

processing
feelings
implement
healthy
personal
hygiene
practices
by
attending
community
pee
improve
relationship
skills

identify
communicate
triggers
of
anger
improve
social
skills
by
identifying
verbalizing
one
difficulty
related
his
social
impulsive
behavior
during
group
by
raising
his
hand
before
increase
her
ability
to
concentrate
focus
on
a
daily
basis
by
demonstrating
th
increase
relationship
skills
by
identifying
two
social
interactions
communication
increase
stress
management
skills
reduce
irritability
by
respectfully
verbalizing
independently
demonstrate
self
care
needs
by
showering
soap
shampoo
is
no
learn
basic
hygiene
grooming
skills

produce
commit

daily
hygiene
learn
basic
hygiene
grooming
skills

self
initiate
attending
3
independent
making
weekly
contact
2
sober
support
modified
his
her
behavior
pla
present
supervisor
for
disposition
of
services
subsequent
authorization
fo
recognize
manage
cope
symptoms
of
depression

low
self
esteem
feelings
of
anxiety

about
housing
by
verbalizing
thoughts
related
housing
reduce
feelings
of
anxiety

around
not
being
understood

by
verbalizing
thoughts
by
initiating
3
social
interactions
per
week
as
observed
by
staff.
reduce
social
withdrawal

by
actively
participating
in

available
treatments

social
withdrawal

verbalizing
three
triggers
of

reduce
the
need
to
gain
approval
from
staff
by
identifying
verbalizing
at
least
on
regards
past
use
responding
international
self
regulate
emotions
or
behaviors
by
requesting
speak
out
loud
in
group

social
anxiety
by
verbalizing
at
least
3
symptoms
of
anxiety

symptoms
of
depression
understand
the
need
for
good
hygiene
by
reporting
practicing
3
healthy
persona
was
assessed
to
be
at
low
risk
was
determined

was
teary
eyed
while
answering
questions
appeared
have
difficulty
focusing
was
willing
discus
's
current
plan

grades
have
begun
falling

support
person
people
when
linking

other
necessary
service
"stop
breathe
think
yes
or
no
&
how
help
0
times

da
1
how
did
the
individual
react
the
intervention
1
intervention:
what
did
you
attempt
accomplish
the
individual
1
what
safety
issues
were
present
10
pounds
in
the
past
month
2
are
there
any
safety
issues
that
need
to
be
monitored
2
how
do
you
see
the
moving
or
not
moving
toward
the
goal?
if
very
little
or
n
2
if
you
modified
the
intervention
how
did
you
modify
it
as
appropriate
2
what
are
the
plans
for
continuing
work


3
medical
necessity:
what
are
the
mental
health
or
community
functions
that
are
still
no
3
times

da
4
what
is
the
next
step
you
are
planning
to
carry
out?
80%
of
the
time
during
the
first
month
85%
of
the
time
the
next
month
as
reported
by
9
year
old

hx
o
ability
to
complete
her
projects
during
creative
arts
groups
2
times
per
week
for
the
next

about
three
months
ago
abuse
of
prescription
drug
accessing
community
resources
accessing
opportunities
accessing
services
necessary
secure
placement
accompanying

in
public
model
help
practice
appropriate
behavior
i
acknowledged
success
active
listening
skills
activities
of
daily
living
addition
the
following
information
was
reviewed
explained
signed:
hipaa
privacy
addressed

concerns
affect
appropriate
rich
flat
restricted
blunted
agreed
that
it
was
empowering
that
she
was
doing
the
right
thing
to
protect
her
child
agreed
utilize
peer
support
community
resources
or
call
clinician
if
he
feel
alcohol
tobacco
caffeine
abuse
of
prescription
drug
allergies
medication
food
seasonal
also
reports
frequent
crying
spells

extended
period
of
time

impulsive
decision
range
angry
feelings
during
group
x
week
every
week
for
six
months
as
observed
by
staff
any
change
in
any
change
of
symptoms
appearance
older
than
stated
age
younger
than
stated
age
disheveled
clean
neat
od
appear
appeared
disheveled
appeared
interest
appetit
appropriate
behavior
in
the
grocery
store
appropriate
boundaries
arrest
history
when
wha
as
demonstrated
b
as
evidenced
by
as
observed
by
staff
as
part
of
improving
social
skills

improve
self
awareness
by
reporting
staff

as
reporte
as
reported
b
as
seen
by
assessment
regarding
appropriateness
of
placement
assist
in
achieving
the

goal
assisted
in
assisted
in
developing
increased
assisted
in
developing
insight
into
assisting

specific
problem
area
related
activities
such
as
activities
of
daily
at
classmates
while
the
teacher
is
lecturing
not
completing
homework
walking
out
of
class
at
least
twice
a
week
for
the
next
6
months
during
case
management
meetings
pla
attend
junior
college
attitude
cooperative
uncooperative
evasive
awareness
of
illness
bandage
been
receiving
services
through
agency

writer
for
the
past
year
has
mad
began
having

great
deal
of
behavior
overactive
underactive
fidgety
distant
childlike
for

adult
friendly
behavioral
goals
plan
behavioral
prompt
behaviors
as
reported
by
caregiver
or
other
involved
part
being
physically
aggressive
younger
sister
ha
best
way
boredom
phone
calls
from
his
mother
boundarie
brainstormed
possible
solutions
ways
brief
solution
focused
therapy
briefed
parents
abou
bright
affect
bruise
built
rapport
b
by
initiating

time
out
then
reintegrating
into
the
group
by
strategically
helping
by
the
amount
of
support
he
received
from
the
group
quickly
identified
two
triggers
calling
friend
case
management
is
not
skill
development
assistance
in
daily
living
causing

disturbance
cbt
dbt
stress
reduction
technique
changes
plan
monitor
closely
ensure
she
has
sufficient
support
preventive
characteristics
of
thoughts
chasing
the
elephant
around
the
sand
tray
clarified
sought
clarification
coached
on
collaborate
help

overcome
obstacles
or
how
they
might
support
no
community
family
agency
signed
completed
treatment
plan
complaints
of
completed
crisis
assessment
determine
danger
self
completing
daily
weekly
chores
for
the
next
six
months
compiled
expectations
did
not
respond
components
of
assessment
continue
concentrating
as
observed
by
staff
confidentiality
the
limits
of
confidentiality
problem
resolution
advance
directives
confronted
about
connected
comments
consent
conservatorship
office
in
the
development
of
the
treatment
plan
consulting
other
necessary
professional
entities
who
are
not
identified
as
th
continues
be
disruptive
in
class

throwing
pencil
continues
have
difficulty
getting
along
younger
sister
coping
skills
for
anxiety
such
as
writing
going
for

walk
talking

friend
or
painting
coping
skills
for
managing
auditory
hallucinations
for
the
next
six
months
create

plan
avoid
triggering
situations
current
assessment
of
assault
risk
current
assessment
of
suicidal
ideations
current
choice
current
employment
situation
current
medication
prescribed
or
over
the
counter
for
medication
document
dosage
current
recommendations
for
treatment
danger
others
or
level
of
grave
disability
date
of
last
use
decompensation
decrease
symptoms
o
demonstrated
denies
any
suicidal
homicidal
ideation
denies
any
trauma
or
abuse
of
dental
brace
describe
alternative
his
her
behavior
description
of
specific
develope
development
individual
group

identify
verbalize
barriers
focusing
did
not
show
any
indication
difficulty
concentrating
difficulty
falling
asleep
difficulty
focusing
in
class
difficulty
sleeping
directed

attention
directed
comments
directives
acknowledgement
of
receipt
form
cultural
linguistic
needs
provider
list
discuss

symptoms
writer
explained
md
of
peterson
clinic
md
the

discuss
information
discussed

the
need
report
information
child
protective
services
discussed
consequences
o
discussing
release
of
information

important
person
in

life
how
disruptive
behaviors
domestic
violence
center
sadvc
where
she
reported
she
would
feel
out
of
place
plan
drug
use
due

severe
mental
illness
writer
is
not
referring

sexual
assault
duration
of
care
during

upswing
during
intake
answered
questions
one
word
answers
was
fidgeting
frequently
i
during
most
of
the
session
but
appeared
calm
prior
leaving
today
during
the
intake
during
the
last
educated
about
medications
how
they
can
reduce
symptoms
o
education
about
how
symptoms
problem
behaviors
might
be
managed
diet
changes
education
regarding
how
problem
behaviors
are
getting
in
the
way
of
meeting
goals.
educational
stressors
employed
positive
reinforcements
empowered

decrease
overall
anxiety
engaged
in

engaged
in
positive
social
interaction
entirely
trusting
of
clinician
statement
that
she
did
not
provoke
the
attack
is
fearful
o
establishing
contacts
that
are
necessary
to
ensure
the
treatment
plan
is
effectively
examined
benefits
consequences
explained
signed
explored
ideas
abou
expressed

commitment
maintaining
sobriety
however
is
discouraged
b
expressed
that
she
felt
some
relief
in
discussing
the
attack
however
she
was
no
facilitated
for

extended
period
family
sessions
the
focus
on
benefiting
the

the
present
are
als
father
lives
out
of
state
has
ha
feelings
o
feelings
of
hopelessness
by
verbalizing
how
he
or
she
is
feeling
during
communit
feels
unsur
fighting
peers
at
school
financial
including
medi
cal
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6
months
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age
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female
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relevant
history
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care
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esteem



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approval
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by
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or


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information
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releases


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conditions
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health
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stressors
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factors



relevant
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history
mental
health
history



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prior
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father
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where
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requesting
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out
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_x


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with
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person
people



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shook
her
head
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question



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how
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mother
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area



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nightmares
waking
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asleep
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little



social
leisure
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caregivers



speech
soft
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identify


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will
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g



weeklywill
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past
month
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what
are
plans
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?


what
is
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out?



what
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were
present?


who
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as
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person
people
such
as
family
members



why
were
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services
received?


willing
discuss


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makereport
assistance
called
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discussed
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increasing
appropriate


'93stop
breathe
think
'94

0
timesday

80%
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time
during
first
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85%
of
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next
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as
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arts
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reviewed
explained
signed:
hipaa
privacy

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agreed
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empowering
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protect
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education

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time

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angry
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during
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week
every
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six
months
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anxiety
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change


appearance
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disheveled
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as
demonstrated


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assisting
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as
activities
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classmates
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not
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class


attempted


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through
agency
for
past
year
has
made

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behavior


behavioral
expectations

behavioral
goals
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prompts

behaviors

being
physically
aggressive
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sister
has

best
way


better


bizarrely
dressed

body
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boredom
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from
mother


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brainstormed


brainstorm
possible
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ways


brief
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therapy


briefed
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about

bright
affect


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support
received
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calling
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skill
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dbt
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monitor
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ensure
has
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support
prevent

chasing
elephant
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tray


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clarified


clarified
sought
clarification


clinical
guide
'97updated
quality
management
2192010

clothes

coached


collaborate
overcome
obstacles
or
how
might
support
not

commended


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referral

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family
agency
signed
completed
treatment
plan


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completing
daily
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months


complied
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did
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components
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continued

concentrating
as
observed


confidentiality
andlimits
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problem
resolution
advance
directives


conflict

confronted


confronted
about


confused
responding
internal
stimuli

connected
comments


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development
of
treatment
plan


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continually


continues
have
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getting
along
younger
sister


contracted


coordinated


coping
skills
anxiety
such
as
writing
going
for
walk
talking
to
friend
or
painting


coping
skills
managing
auditory
hallucinations
for
next
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months


create
plan
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current
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current
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involvement
law
enforcement
probation
or
parole

current
living
situation

current
medication
prescribed
or
over
the
counter
medication
document
dosage


currently
reports


danger
others
or
level
grave
disability


decide


decompensation


decreasing


demeanor


demonstrated


denies
any
suicidal
homicidal
ideation


dental
braces

depressed


depression

describe


describe
alternative
her
behavior

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developed


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individual
group
identify
verbalize
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class


directed
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directives
acknowledgement
receipt
form
culturallinguistic
needs
provider
list


discussed

discussed


discussed
consequences


discussed
withneed
report
information
child
protective
services


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symptoms
explained
md
peterson
clinic
md

disruption


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domestic
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sadvc
where
reported
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out
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drug
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due
tosevere
mental
illness
is
not
referring
sexual
assault


during
an

'93upswing
'94

during
intake
answered
questions
one
word
answers
fidgeting
frequently


during
most
of
session
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prior
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today


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intake


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educated


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how
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emphasized


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overall
anxiety


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entirely
trusting
clinician
statement
that
did
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provoke
attack
is
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established


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evaluated


examined


examined
benefits
consequences


excoriations

explained


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signed


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explored
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about

expressed

facilitated
for
an
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father

father
lives
out
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has
had

feelings


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how
is
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during
community

feels
unsure

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peers
at
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flat
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concentration

focused


focused
issues


following


for
the
next
few
months


four


frequency


friend

friendly
disposition

from

frustration

functions
meetings
appropriately
groomed
showered
clean
clothing
teeth
brushed
deodorant


funny

gave
cues
prompts


gave
homework
assignment


generated

gestures
andor
attempts
information
must
be
documented


get
there

glasses

gonna
sleep
tonight
experiencing
nightmare

going
to
take?
'94
rolled
her
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informed
that
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guided


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hospitalized
three
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suicide
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hashhistory


health

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reflect
progress
have
made
so
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helping
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understand
accept
condition

her
chair
approx
halfway
through
assessment
asked

'93how
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thing

her
self
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about
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hid
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improvement
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clinician
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regarding

her


history
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gestures
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honestly
commit
maintaining
medication
compliance
sobriety
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from

hopelessness

hopes


household
chores


hx


hygiene

hygiene
skills
as
observed
by
for
next
months


hyperactivity
in
classroom


hypersomnia


identified

identified


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barriers
participating
group
for
the
next
six
months


identifying


identifying
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provoking
trigger
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clinical
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assessment
is:

Presenting
problem,
including
the
current
symptoms
and
relevant
conditions
affecting
mental

Psychiatric
symptoms

family
composition

Medical
History

Current
Five
Axis
Diagnosis

Current
Mental
Status
Exam

Current
Recommendations
for
treatment
Other
paperwork
to
be
completed
annually:

Releases

Authorization
Form

Medical
Necessity

Consents

Client
Plan

Financial,
including
Medi-Cal
eligibility

and
any
change
of
symptoms
in
the
last
year
Any
change
in

10

amount

Behaviors
reported


caregiver
or
other
involved
party

completed

crisis

discouraged

evaluated


every
month


however


identifying


improve

improve
social
skills

improving

initiating

initiating
#
social
interactions

week

internal
barriers

living
skills
groups
each
week

reported

observed


month

reported


observed


next
six
months

number

clean
sober
person

reported

weekly

observed


observed



part


people

people
places
things

placed

5150
hold

proof


reduce
risk

relapse


reduce
social
anxiety


reported


reported



reporting
reporting


routine

self
awareness


social
skills

Socialization

supplies

Symptoms


taking
medication
teacher

time
out

triggers


Twice
week

unprompted



verbalize
effective
was
medically
cleared


week
every
week

#
months

Weekly

without
prompting




writing


decrease
symptoms
of
increase
appropriate

increase
level
of

0
times
a
day
to
3
times
a
day
as
reported
by
as
evidenced
by

as
seen
by

as
demonstrated
by
Twice
a
week
in
Socialization
Group
and
as
reported
by
staff,
the
pt
will
verbalize
effective
coping
skills
for
managing
auditory
hallucinations
for
the
next
six
months.

Three
times
a
week
in
Symptom
Reduction
group
and
as
observed
by
staff,
the
pt
will
identify
barriers
to
participating
in
group
for
the
next
six
months.

Once
a
week
in
Community
group
and
as
observed
by
staff,
the
pt
will
identify
barriers
to
completing
daily/weekly
chores
for
the
next
six
months.

Once
a
week
in
Life
Skills
group
and
as
observed
by
staff,
the
pt
will
process
and
explore
school/work
options
for
the
next
six
months.

Twice
a
week
in
Symptom
Reduction
group
and
as
observed
by
staff,
the
pt
will
identify
triggers
of
paranoid
ideation
or
hypomanic
episodes
for
the
next
six
months.

Weekly
in
Life
Skills
group
and
as
observed
by
staff,
the
pt
will
identify
internal
barriers
to
taking
medication
unprompted
by
staff
for
the
next
six
months.

Three
times
a
week
in
Life
Skills
group
and
as
observed
by
staff,
the
pt
will
identify
socially
inappropriate
behaviors
and
express
acceptable
behaviors/verbalizations
for
the
next
six
months.

pt
will
reduce
social
anxiety
by
initiating
3
social
interactions
per
week
as
observed
by
staff
for
the
next
6
months.

pt
will
reduce
social
anxiety
related
to
his
persistent
mental
illness
by
identifying
emotional
triggers
and
communicating
related
feelings
2
times
per
week
as
observed
by
staff
for
the
next
6
months.

pt
will
effectively
manage
social
anxiety
by
verbalizing
at
least
3
symptoms
of
anxiety
at
least
once
a
week
as
observed
by
staff
for
the
next
6
months.

pt
will
effectively
manage
anxiety
related
to
h/her
persistent
mental
illness
by
sharing
h/her
symptoms
of
anxiety
and
appropriate
coping
techniques
3
times
a
week
for
the
next
6
months.

pt
will
reduce
feelings
of
anxiety
around
not
being
understood
by
verbalizing
thoughts
__x/week
every
week
for
six
months
as
observed
by
staff.

pt
will
reduce
feelings
of
anxiety
about
housing
by
verbalizing
thoughts
related
to
housing
__x/week
every
week
for
six
months
as
observed
by
staff.


As
part
of
improving
social
skills,
pt
will
improve
self-awareness
by
reporting
to
staff
1
negative
and
1
positive
social
interaction
2
times
a
week
for
the
next
6
months.

pt
will
improve
social
skills
by
identifying
and
verbalizing
one
difficulty
related
to
his
social
interactions
twice
a
week
for
the
next
6
months
as
observed
by
staff.

To
improve
relationship
skills,
pt
will
identify
and
communicate
triggers
of
anger
and
irritability
that
surface
during
interactions
at
least
2
times
a
week,
as
observed
by
staff,
for
the
next
6
mos.

pt
will
reduce
social
withdrawal
by
actively
participating
in
available
treatments/social
resources
at
least
3
times
a
week
as
observed
by
staff
for
the
next
6
months.

pt
will
reduce
social
withdrawal
by
identifying
and
verbalizing
three
triggers
of
isolation
as
observed
by
staff
__x/week
every
week
for
six
months.

pt
will
increase
relationship
skills
by
identifying
two
social
interactions
and
communicating
these
feelings
__x/week
during
process
groups
as
observed
by
staff
for
six
months.

At
least
twice
a
week
for
the
next
6
months
(during
case
management
meetings;
plan
development;
individual,
group,
pt),
pt
will
identify
and
verbalize
barriers
to
focusing
and
concentrating
as
observed
by
staff.

pt
will
increase
her
ability
to
concentrate
and
focus
on
a
daily
basis
by
demonstrating
the
ability
to
complete
her
projects
during
Creative
Arts
groups
2
times
per
week
for
the
next
6
months,
as
observed
by
staff.

pt
will
understand
the
need
for
good
hygiene
by
reporting
and
practicing
3
healthy
personal
hygiene
skills
as
observed
by
staff
for
the
next
6
months.

pt
will
implement
healthy
personal
hygiene
practices
by
attending
community
and
peer
functions/meetings
appropriately
groomed
(showered,
clean
clothing,
teeth
brushed,
deodorant)

To
learn
basic
hygiene
and
grooming
skills,
pt
will
produce
and
commit
to
a
daily
hygiene
routine
as
reported
by
pt/observed
by
staff.

To
learn
basic
hygiene
and
grooming
skills,
pt
will
purchase/obtain
at
least
2
grooming
supplies
every
month
as
reported
by
pt
observed
by
staff.

To
learn
basic
hygiene
and
grooming
skills,
pt
will
self-initiate
attending
3
independent
living
skills
groups
each
week
as
reported
by
pt
observed
by
staff.

pt
will
independently
demonstrate
self-care
needs
by
showering
with
soap
and
shampoo
without
prompting
from
staff
at
least
_x’s
week
every
week
for
6
months
as
reported
by
pt
observed
by
staff.

pt
will
demonstrate
to
staff
_x’s
a
week
the
ability
to
prepare
well
rounded
and
balanced
meals
as
observed
by
staff.

pt
will
demonstrate
effective
independent
living
skills
by
laundering
clothes
at
least
_x’s
a
month
as
reported
by
pt/
as
observed
by
staff.

pt
will
demonstrate
an
understanding
of
Board
and
Care
rules
by
complying
with
the
rules
80%
of
the
time
during
the
first
month,
85%
of
the
time
the
next
month…,
as
reported
by
pt/
as
observed
by
staff.

pt
will
effectively
manage
symptoms
related
to
schizophrenia,
e.g.,
responding
to
internal
stimuli,
by
verbalizing
3
coping
skills
3
times
a
week
as
observed
by
staff
for
the
next
6
months.

pt
will
effectively
manage
symptoms
of
depression,
e.g.,
feelings
of
hopelessness,
worthlessness,
and
low
self-esteem,
by
verbalizing
feelings
related
to
his/her
mental
illness

pt
will
recognize,
manage,
and
cope
with
symptoms
of
depression,
e.g.,
low
self-esteem
and
feelings
of
hopelessness,
by
verbalizing
how
he/she
is
feeling
(during
Community

Meeting,
case
management
sessions,
pt)
__x/week
every
week
for
six
months
as
observed
by
staff.

pt
will
decrease
irrational
internal
stimuli
that
contribute
to
feeling
anxious
by
weekly
identifying
1
anxiety
provoking
trigger
for
the
next
6
months
as
reported
by
pt
observed
by
staff.


pt
will
develop
a
healthy
support
system
by
obtaining
and
utilizing
at
least
1
telephone
number
of
a
clean
and
sober
person
as
reported
by
pt
weekly.

pt
will
develop
a
healthy
support
system
by
making
weekly
contact
with
2
sober
support
people
as
reported
by
pt

pt
will
develop
a
healthy
support
system
by
attending
at
least
3
12-step
meetings
a
week
as
reported
by
pt
and
with
proof
of
a
completed
sign-in
sheet.

Weekly,
pt
will
reduce
risk
of
relapse
by
identifying
in
writing
at
least
10
triggers,
e.g.,
people,
places
and
things,
as
reported
by
pt/observed
by
staff.

Weekly,
pt
will
verbalize
at
least
2
statements
of
acceptance
regarding
his/her
addiction
as

pt
will
effectively
manage
impulsive
behavior
during
group
by
raising
his
hand
before
speaking
out
loud
3
times
a
week
as
observed
by
staff
for
the
next
6
mos.

pt
will
reduce
the
need
to
gain
approval
from
staff
by
identifying
and
verbalizing
at
least
one
new
coping
skill
for
increasing
emotional
independence
each
week
for
the
next
6
months
as
observed
by
staff.

Page
71
of
97
pt
Plan
Library,
Continued

pt
will
self-regulate
emotions
and/or
behaviors
by
requesting
to
speak
out
loud
in
group
_x
times
a
week
as
observed
by
staff
for
the
next
6
mos.

pt
will
increase
stress
management
skills
to
reduce
irritability
by
respectfully
verbalizing
angry
feelings
during
group
__x/week
every
week
for
six
months
as
observed
by
staff.

and
assist
assisted
decrease
for
help
in
increase
on
pt
pt's
the
the
pt
their
them
they
was
when
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Initial
Evaluation
Intake
Assessment

|
Strengths
|-


|
Reason
For
Referral
|-
Presenting
Problem:

-
History
And
Onset
Of
Presenting
Problem:


-
Developmental
And
Family
History
As
It
Relates
To
The
Presenting
Issue:


-
Current
Family
Information
As
It
Relates
To
Presenting
Issue:




|
Current
Symptoms,
Stressors
And
Behaviors
|

-


|
Medical
Necessity:
Level
Of
Functioning,
And
Functional
Capacity
|

-
[1].


Is
Client's
Impairment
In
Functional
Capacity
The
Result
Of
A
Mental/Emotional
Disturbance?
(Yes/No):


-
[2].


Does
Client's
Mental/Emotional
Disturbance
Significantly
Impair
Their
Functional
Capacity
Within
An
Important
Area
Of
Life
Functioning?
(Yes/No):


-
[3].


Does
Client's
Mental/Emotional
Disturbance
Create
For
The
Probability
Of
Significant
Deterioration
In
An
Important
Area
Of
Life
Functioning?
(Yes/No):


-
[4].


Does
Client's
Mental/Emotional
Disturbance
Create
For
The
Probability
That
The
Child/Youth
Will
Not
Progress
Developmentally
As
Individually
Appropriate?
(Yes/No/Not
Applicable):


-
[5].


Is
Client's
Mental/Emotional
Disturbance
A
Condition
Which
Specialty
Mental
Health
Services
Could
Correct
Or
Ameliorate?
(Yes/No):


-
[6].


Given
The
Nature
Of
The
Functional
Impairment
Noted
Above,
Treatment
Services
Will
Significantly
Reduce
And/Or
Prevent
Significant
Deterioration
In
Functioning,
And
Because
Of
That,
The
Following
Domain/Domains
Of
Functioning
Will
Be
Treated:

[
]
Home
And
Living
Situation

[
Yes
]
Social/Peer
And
Interpersonal
Relationships

[
]
Work/Occupation

[
]
School

[
]
Daily
Activities

[
]
Financial

[
]
Health/Medical

[
]
Family
Relationships

[
]
Legal
&
Safety

[
]
Potential
For
Exploitations

[
]
Cultural
Components

|
Psychosocial
Factors
|

-
Current
Living
Situation:
-
Educational
Attainment,
Include
Highest
Level
Of
Education
Completed:


-
Vocational
(Include
Current
Employment
Status):


-
Daily
Activities
(How
Does
Client
Spend
Their
Day
And
Are
They
Able
To
Attend
To
Activities
Of
Daily
Living?):


-
Cultural
&
Linguistic
Factors:


-
Relationships


---
Family
Relationships

------
Family
Of
Origin:


------
Immediate
Family:


---
Social/Friend
Relationships:


---
Support
Network:


-
History
Of
Trauma/Exposure
To
Trauma:


-
Legal
(Include
Conservatorship,
Probation,
Family
Court,
Litigation,
Etc.
If
Applicable):


-
Spiritual
Factors:

|
Psychiatric
History
|

[1]
-
Has
Client
Participated
In
Counseling/Psychotherapy
Services
In
The
Past?


-
If
Yes,
Please
Describe...

---
Provider:


---
Treatment
Date
Range
(Start/End
Date):


---
Therapeutic
Modalities:


---
Client's
Response
To
Treatment:


---
Psychiatric
Hospitalizations:


---
Information
From
Other
Source
Of
Clinical
Data:



[2]
-
Has
Client
Participated
In
Psychiatric/Medication
Management
Services
In
The
Past?

-
If
Yes,
Please
Describe
When,
With
Whom,
And
Experience:


-
If
Yes,
Please
Specify
Medication
Name,
Dosage,
What
The
Medication
Is
For,
And
Prescribing
Provider:


|
Current
Risks
|-
No
Risks
Present
At
Time
Of
Intake.


-
Does
Client
Have
A
History
Of
Trauma/Exposure
To
Trauma?
(Yes/No/Unknown
At
This
Time):


-
This
Writer
Rendered
Risk
Assessment
For
S/I
And
H/I;
Client
Denied,
Unable
To
Specify
Plans,
Means,
Motivation,
Intent;
Client
Described
Content
Associated
With
Future
And
Goals
Associated
With
Establishing
Positive
And
Meaningful
Interpersonal
Relationships
In
Their
Community.

|
Medical
History
|

-
Current
Physical
Condition/Illness:


-
Primary
Care
Physician
(Name,
Address,
Phone):


-
If
Child/Adolescent,
Describe
Developmental
History
And/Or
Prenatal/Perinatal
Events:

|
Medications
|

-
Is
Client
Actively
Taking
Medication
At
This
Time?


-
If
Yes,
Please
Specify...

---
Medication
Name:


---
Start
&
End
Date
Of
Medication
(Ie.,
Fall
2012
-
Present):


---
Reason
For
Use:


---
Amount/Dosage:


---
Frequency:


-
Allergies
To
Medication
Or
Adverse
Reactions?
(Must
Specify
Yes/No):


|
Substance
Use
|

-
Substance
Types
May
Include,
But
Are
Not
Limited
To:
Alcohol,
Amphetamines,
Cocaine,
Opiates,
Sedatives,
Pcp,
Hallucinogens,
Inhalants,
Marijuana,
Nicotine,
Rx
Drugs.


-
Is
Client
Actively
Using
Substances?

---
Substance
Type:


---
Onset:


---
Dosage/Amount:


---
Frequency
Of
Use:


---
Date
Of
Last
Use:

-
If
Yes,
Is
Action
Required?


-
If
Yes,
How
Is
Substance
Use
Impacting
Mental/Emotional
Health?
}

The
psychosocial
assessment
is
the
intervention.
In
addition,
the
following
information
was
reviewed,
explained,
and
signed:
Informing
Materials,
HIPAA
Privacy
Practices,
Confidentiality
and
the
Limits
of
Confidentiality,
Problem
Resolution,
Advance
Directives,
Provider
List,
Acknowledgement
of
Receipt
form
and
Cultural/Linguistic
issues
were
also
reviewed.

This
session
was
interactive
because
of
the
utilization
of
sand
tray
with
pt
to
assist
pt
in
being
able
to
provide
information.
The
psychosocial
assessment
is
the
intervention.
In
addition,
the
following
information
was
reviewed,
explained,
and
signed:
HIPAA
Privacy
Practices,
Confidentiality
and
the
Limits
of
Confidentiality,
Problem
Resolution,
Advance
Directives,
Acknowledgement
of
Receipt
form,
Cultural/Linguistic
needs
and
Provider
List.
The
following
information
was
reviewed,
explained,
and
signed

Discussed
with
pt
the
need
to
report
this
information
to
Child
Protective
Services,
and
pt
was
willing
to
make
the
report
with
this
writer’s
assistance.
This
writer
called
CPS,
and
provided
support,
encouragement
and
guidance
to
pt
as
she
provided
information
to
the
CPS
social
worker.
After
the
report
was
made,
this
writer
processed
the
experience
with
pt
regarding
making
the
report
and
attempted
to
reframe
the
experience
in
an
empowering
way.


utilized
a
structured
card
game
that
required
participants
to
maintain
focus
and
tracking.
Worked
with
pts
on
identifying
how
they
felt
internally
when
frustrated
by
the
structured
task.
Progressive
relaxation
techniques,
and
self-soothing
exercises,
and
time
outs
were
also
introduced.
These
were
utilized
to
assist
pts
in
this
focusing
activity
as
well
as
the
use
of
“time-outs”
as
warranted
and
needed.
Activities
were
utilized
to
assist
pts
in
sustaining
his/her
focus
on
activities.

Communication,
coordination,
and
referral

Monitoring
to
ensure
a
pt’s
access
to
services

Monitoring
the
pt’s
progress

Relaying
information
that
is
medically
necessary
from
pt,
therapist,
case
manager,
or
psychiatrist
to
another
person

linking
pts
to
necessary
services

consulting
with
other
necessary
professional
entities
(who
are
not
identified
as
the
pt’s
support
person/people)
when
linking
pt
to
other
necessary
services

gathering
information
that
will
benefit
pt
in
receiving
necessary
services
from
sources
(who
are
not
identified
as
the
pt’s
support
person/people)
such
as
family
members,
medical
providers,
social
workers
and
educators,

making
referrals
to
providers
for
needed
services

monitoring
the
activities
for
necessary
follow
up
(i.e.,
ensuring
that
resources
that
pt
is
accessing,
to
assist
pt
in
order
to
meeting
treatment
goals
are
assisting
pt
in
the
most
efficient
and
helpful
way)

Establishing
contacts
that
are
necessary
to
ensure
the
treatment
plan
is
effectively
implemented
and
that
progress
toward
goals
are
being
made.
Case
Management
is
NOT
skill
development,
assistance
in
daily
livi

Assessment
regarding
appropriateness
of
placement.

Needs
determination

Locating
and
securing
an
appropriate
living
environment

Pre-placement
visit(s)

Securing
housing
or
placements

Placement
and
placement
follow-up

Accessing
services
necessary
to
secure
placement.


Release
of
Information
obtained.
T

This
clinician
was
able
to
speak
to
MD
that
afternoon
to
discuss
pt’s
symptoms.
This
writer
explained
to
MD
of
Peterson
Clinic
MD
the
pt’s
physical
symptoms
and
the
need
for
special
accommodations.
MD
agrees
agreed
to
allot
extra
time
to
see
this
pt
Assisting
with
a
specific
problem
area
related
to
such
activities
as
Activities
of
Daily
Living
(ADLs)

Showing
pt
how
some
obstacle
might
be
overcome
(i.e.,
how
to
obtain
a
bus
pass
when
pt
has
difficulty
making
decisions)

Identifying
obstacles
(i.e.,
pt
wishes
to
attend
Junior
College
but
has
difficulty
getting
up
in
the
morning,
does
not
know
how
to
use
public
transportation,
and
has
not
gotten
necessary
hearing
aids)

Helping
strategize
with
pt
about
what
they
can
accomplish.
(i.e.,
prioritizing
household
chores)

Education
regarding
how
problem
behaviors
are
getting
in
the
way
of
meeting
goals

Education
about
how
symptoms/problem
behaviors
might
be
managed
(i.e.,
diet
changes,
medication)

Accompanying
a
pt
in
public
to
model
and
help
pt
practice
appropriate
behavior
in
public
(i.e.,
accompanying
a
pt
to
the
grocery
store
to
assist
pt
in
practicing
appropriate
behavior
in
the
grocery
store)

helping
significant
support
persons
to
understand
and
accept
the
pt’s
condition

involving
identified
significant
support
person/people
in
planning
of
and
implementation
of
pt
plan(s)

Sessions
with
pt’s
family
(if
they
are
identified
as
significant
support
person/people)
on
behalf
of
pt
with
the
intent
of
benefiting
pt

Family
sessions
with
the
focus
on
benefiting
the
pt,
with
the
pt
present,
are
also
included
in
Collateral.

Obtaining
information
from
an
important
person
in
pts
life

Discussing
(with
Release
of
Information)
with
an
important
person
in
pt’s
life
how
to
collaborate
and
help
pt
to
overcome
obstacles,
or
how
they
might
support
(and
not
hinder)
some
area
of
improvement
in
functioning.

due
to
recent
increase

pt
is
not
sleeping
well,
is
becoming
increasingly
manic
and
appears
to
be
hearing
voices
Will
discuss
information
with


Completed
crisis
assessment
to
determine
Danger
to
Self,
Danger
to
Others,
or
level
of
grave
disability.

focused
on
issues
of
will
teach


assist
the
pt
in
achieving
the
pt’s
goals


Symptom
Reduction
group;
Living
Skills
group;
and
providing
feedback
from
staff
in
Community
group,
Case
Management,
Medication
Support
Intervention
Starters
(depends
on
service
activity)
¾
Acknowledged
pt
¾
Assisted
pt
with
¾
Assisted
pt
to
¾
Briefed
pt/parents,
etc.
about
¾
Brainstormed
possible
solutions/ways
to
¾
Built
rapport
by
¾
Commended
pt
¾
Consulted
with

¾
Coordinated
with

¾
Cued
pt
¾
Developed
¾
Directed
pt/pt’s
attention
¾
Discussed
¾
Discussed
consequences
of
¾
Employed
positive
reinforcements
to
¾
Encouraged
pt
to
¾
Engaged
pt
in
positive
social
interaction
¾
Explored
ideas
about
¾
Facilitated…for
an
extended
period
¾
Gave
cues/prompts
to
¾
Generated
¾
Identified
¾
Implemented
¾
Informed
¾
Intervened
when
¾
Intervened
with
¾
Located
¾
Maintained
¾
Monitored

maintenance
of

¾
Monitored
pt’s

interactions
with
peers

¾
Observed
¾
Offered

¾
Offered
to
¾
Practiced

¾
Praised
¾
Prompted
pt
to
comply
with
expectations
¾
Problem
solved
¾
Prompted
pt
to

¾
Provided
frequent

¾
Redirected
¾
Reframed
¾
Reminded
¾
Reviewed

pt’s

¾
Role
modeled
¾
Set
clear

limits/boundaries
¾
Suggested
¾
Supported
¾
Used
humor
to

Assisted
pt
with

for


an
extended
period
of
time/

in
a
variety
of
settings.
¾
Assisted
pt
with

to

interact
with
others/peers

in
a

out
in
the
community.
¾
Brainstormed
with
pt

possible
alternatives
to…

describe
alternative
to
his/her
behavior
¾
pt
seemed

redirection.
¾
Role

with

______

meeting…
…to
assist
pt
with

his/her

behavioral
goals/plan.

¾
Assisted
pt
in
developing
increased

/hygiene/
personal
safety/the
usefulness
of

an
education…
¾
Engaged
pt
in
a

problem-solving
session

regarding…
¾
Upon
this
staff’s
arrival,

pt
appeared
/seemed/
to
be

in

a

…describe

the

with
a

qualifyingstatement

i.e.

bright
affect,

flat
affect,

/demeanor,

talkative,


with

description
of
specific,

Current
legal
involvement
with
law
enforcement,
probation,
or
parole

Arrest
History
(when
and
what)

Past
legal
involvement
with
law
enforcement,
probation,
or
parole

Past
or
current
involvement
with
Child
Welfare
Services
(CWS)

Involvement
with
Public
Guardian/Administrator’s
office


will

week

as
observed
by
Once

as
observed
by




develop

healthy
support
system

by


verbalizing



reduce

or

To
learn
basic
hygiene

grooming
skills

community
resources

having

Met
with


observed
by



reports

needs
approval


brainstormed
possible
solutions
ways


briefed
parents
about

comply


description


expectations

facilitated
an
extended
period

hygiene


six
months


specific


upon
arrival


variety
settings


week
every
week

an
education

an
extended
period
time

assist

assisted

describe
alternative
behavior
developing

from

guardian

increased

interact

involvement

meeting

parent

peers

personal
safety

an

assessment



attack


authorization
for
due
to

present

pt

session

Subsequent
to

supervisor

Current
medication
(prescribed
or
over-the-counter)
For
medication,
document
dosage
and
frequency.

Relevant
Prior
Medications

Medical
Issues

Allergies
(to
medication,
food,
seasonal,
etc.)

Hospitalizations

Surgeries

Illnesses

For
children,
document
developmental
history,
including
prenatal
and
perinatal
events

Appearance
(i.e.,
older
than
stated
age,
younger
than
stated
age,
disheveled,
clean,
neat,
odd
appearance,
etc)

Behavior
(i.e.,
overactive,
under
active,
fidgety,
distant,
childlike
(for
an
adult),
friendly,
impulsive,
etc.)

Attitude
(i.e.,
cooperative,
uncooperative,
evasive,
etc.)

Mannerisms
(i.e.,
gestures,
tics,
grimacing,
etc.)

Page
61
of
97
Components
of
Assessment,
Continued

Posture
(i.e.,
slumped,
relaxed,
stooped,
etc.)

Speech
(i.e.,
soft,
coherent,
incoherent,
rambling,
pressured,
etc.)

Affect
(i.e.,
appropriate,
rich,
flat,
restricted,
blunted,
etc.)

Mood
(i.e.,
euthymic,
depressed,
elevated,
etc.)

Characteristics
of
thoughts
(i.e.,
illusions,
paranoia,
grandiosity,
hallucinations,
delusions,
etc.)

Orientation
(i.e.,
person,
place,
time)

Memory
(i.e.,
remote,
recent,
immediate,
etc.)

Intellectual
functioning

Eye
Contact

Awareness
of
illness

Appetite

Sleep
(i.e.,
nightmares,
waking
frequently,
difficulty
falling
asleep,
sleeping
too
little,
sleeping
a
great
deal)

1
What
safety
issues
were
present?
2
Are
there
any
safety
issues
that
need
to
be
monitored?
3
Medical
Necessity:
What
are
the
mental
health
or
community
functions
that
are
still
not
1
pt
Intervention:
What
did
you
attempt
to
accomplish
with
the
individual?
2
If
you
modified
the
intervention;
how
did
you
modify
it
as
appropriate?
1
How
did
the
individual
react
to
the
intervention?
2
What
are
the
plans
for
continuing
to
work
with
this
pt?
2
How
do
you
see
the
pt
moving
or
not
moving
toward
the
goal?
If
very
little
or
no
progress,
explain
why.
4
What
is
the
next
step
you
are
planning
to
carry
out?

Will
present
to
supervisor
for
disposition
of
services.
Subsequent
to
authorization
for
ongoing
outpatient
mental
health
services,
pt
will
return
to
develop
pt
plan.
Total
Time:
93
Min.

ongoing
outpatient
mental
health
services,
pt
and
mother
will
return
to
develop
pt
plan.

Due
to
pt’s
severe
mental
illness,
this
writer
is
not
referring
pt
to
Sexual
Assault
and
Domestic
Violence
Center
(SADVC)
where
she
reported
she
would
feel
out
of
place.
Will
plan
to
use
cognitive
techniques
and
will
consult
with
psychiatrist
regarding
possible
medication
changes.
Will
plan
to
monitor
pt
closely
to
ensure
she
has
sufficient
support
to
prevent
decompensation.

Symptoms
as
reported
by
pt,
caregiver,
or
other
involved
party
(i.e.,
a
teacher
reporting
hyperactivity
in
the
classroom)

Behaviors
as
reported
by
pt,
caregiver,
or
other
involved
party

Frequency
of
symptoms
and
behaviors
(Be
as
specific
as
possible.
This
may
help
you
when
writing
the
pt
Plan
goals.)

Precipitating
events/stress

History
of
Trauma
or
Abuse
(physical,
sexual,
emotional).
Witnessing
Domestic
Violence
would
also
be
pertinent
information.

Other
relevant
history
(i.e.,
familial
relationship
issues)

Relevant
conditions
affecting
mental
health
(i.e.,
physical
stressors,
relationship
factors,
living
conditions,
job/employment/educational
stressors,
etc)

Medical
conditions
that
could
be
affecting
mental
health

History
of
presenting
problem
(i.e.,
when
did
the
symptoms
begin?)

If
completing
a
child’s
assessment,
also
document
the
response
of
the
caregivers
to
the
symptoms
and/or
behaviors.

agression
lack
of
skill
set
inappropriate
interaction
with
others
lack
of
support
lack
of
access
inadequate
ability
to
pt
presents
with

complaints
of

problems
with
family
inability
to
keep
employment
which
result
in

over
spending

pt
appears
denies
any
suicidal/homicidal
ideation.

pt
denies

pt
is

currently

on
unemployment
which
will
soon

pt
was
arrested
in
another
county

causing
a
disturbance

a
store.

Has
a
history
of

during
the
last

the
first
at
age
23

Met
with
pt

and
pt

to
complete
intake
paperwork.

pt
is
a
9
year
old
Caucasian
female,
presenting
with


difficulty
sleeping,


weight
loss
(Approx.
10
pounds
in
the
past
month),
and
having


great
difficulty
communicating
with
peers
or
family.
pt
answered
a
couple
of
questions
with
a
“yes”
or
“no”
answer,

pt
was
mostly

during
the
intake.

made
little
eye
contact
and

hid
her
face
behind
hair.
pt
reports
that

about
three
months
ago,

pt
began
having
a
great
deal
of

difficulty
focusing
in
class,
and

pt’s
grades
have
begun
falling.

pt
also
reports
frequent
crying
spells.

pt
denies
any
trauma
or
abuse
of
pt;

pt
shook
her
head
in
response
to
the
question.

pt
reports
that
she
and
father
are
divorced;

father
lives
out
of
state
and
has
had
little
contact
with
pt
for
several
years.

Met
with
pt
to
complete

pt
has
a
hx
of
severe
major
depressive
sx,
and

has
been
hospitalized
three
times
in
the
past
year
for
suicide
attempts.

Currently,
pt
reports

hypersomnia,

low
appetite,
difficulty
concentrating,
and

poor
memory,

reports
no
S/I
or
H/I.

She
is
currently
receiving
medication
services
from
YCADMH
and
reports
taking
her
medication
regularly.
pt
has
a
hx
of

disruptive
behaviors,

including
throwing
things
at
other
people,
fighting
with
peers
at
school,
and

being
physically
aggressive
with
younger
sister.
pt
has
been
receiving
services
through
this
agency
and
with
this
writer
for
the
past
year,
and
has
made
some
small
progress
on
goals.

pt
continues
to
be
disruptive
in
class
(e.g.,
throwing
pencils
at
classmates
while
the
teacher
is
lecturing,
not
completing
homework,
walking
out
of
class)
and
continues
to
have
difficulty
getting
along
with
younger
sister.

pt
has
been
suspended
from
school
once
in
the
past
6
months,
and
this
was
due
to
starting
a
fight
with
another
student.

reports
that
she
is
having
intrusive
thoughts
and
related
to
a

sexual
assault
she
endured

while
homeless
last
year.

She
has
not
told
anyone
about
this
assault

her
self-blaming
about
the
attack.


functional
skills

daily
living
skills

social
and
leisure
skills

grooming
and
personal
hygiene
skills

Met
with
pt


to
work
on

with
a
focus
on

skillbuilding
tasks.

The
goal
that
is
being
focused
on
today

relates
to

impulsivity.
Previous
mental
health
providers
(include
location,
provider,
date,
and
duration
of
care,
if
at
all
possible)

Past
hospitalizations
(include
location,
provider,
date,
and
duration
of
care,
if
at
all
possible)

Why
were
the
previous
services
received?

Under
what
circumstances
did
the
pt
receive
services?


Current
employment
situation/employment
history

Marital
Status

Social
Support
Network
(for
a
child
assessment,
document
caregivers).

Relevant
family
history
(abuse,
neglect,
substance
abuse
history,
mental
health
history,
chronic
illness)

For
children,
document
school
functioning.
The
assessment
form
requires
that
information
regarding
grade
and
school,
academic
ability,
achievements,
any
special
education
participation,
and
vocational
goals
must
be
documented.


clinician
was
able



speak


pt’s
symptoms


pt’s


discuss


writer
explained


any
change
of
symptoms


in
last
year

Approx
halfway
through
assessment


asking
writer

repeat
question


While
discussing
pt’s
suicidal
or
homicidal

Clinician


condition
is
deteriorating


identifying
how
they
felt
internally
when
frustrated
by


pt
asked


pt
will
consult
with


psychiatrist


reintegration


pt
proceeded

engage
successfully
in
activity
without
further

reports
taking
medication
regularly


rolled
eyes


self
blaming


session
was
interactive
because
of
utilization
of
sand
tray
with
pt

assist
pt

Symptom
Reduction
group
Living
Skills
group
providing
feedback
from

there
were
several
questions
still
needing

be
answered


tracking
Worked
with
pt
on


when


writer
pt
discussed
goals
of
increasing
appropriate

writer
informed
pt


every
week
for
#
months


every
week


#


as
observed
by


hx
of

accessing


an
extended
period
of
time


As
part
of
improving
social
skills
pt
will
improve
self
awareness
by
reporting

staff
1

assist
pt
in
achieving
pt’s
goals

by
taking

communicating


Completed
crisis
assessment

determine
Danger

Self


description
of
specific


great
difficulty


in
variety
of
settings


interventions
monkey

peers
or
family


pt
appeared
pleased
with
goals
decided
upon
pt
expressed
he
could

pt
appreciative
of
intervention
reports
drop

pt
identified
their
own
triggers


pt
is
9
year
old
Caucasian
female
presenting
with


pt
was
assessed

be
at
low
risk


pt
was
determined

be

pt
was
teary
eyed
while
answering
questions


appeared

have
difficulty
focusing

pt
was
willing

discuss

spent
some
time
processing
through
feelings


talking
over


psychosocial
assessment
is
intervention


In
addition


following
information
was

utilized


structured


card
game


required



maintain
focus

weight
loss
Approx
#
pounds
in
past
#
month


Will
present

supervisor
for
disposition
of
services


Subsequent

authorization
for

writer
assisted

pt
understands


assist
pt
with

“yes”
or
“no”

&
how

help

Accessing
services
necessary

secure
placement

Accompanying
pt
in
public

model

Affect
appropriate
rich
flat
restricted
blunted

Allergies

medication
food
seasonal

Arrest
History
when
what
Assessment
regarding
appropriateness
of
placement

At
least
twice
week
for
next
6
months
during
case
management
meetings
plan
Attitude
cooperative
uncooperative
evasive

overactive

under
active

fidgety

distant

childlike
for
an
adult

friendly

Behaviors
as
reported
by
pt

caregiver

other
involved
party
Characteristics
of
thoughts

illusions

paranoia

grandiosity

hallucinations

delusions

consulting
with
other
necessary
professional
entities

who
are
not
identified
as

Current
assessment
of
assault
risk

documentation
as

what
information

assessment
Current
assessment
of
suicidal
ideations
gestures

or
attempts

documentation
as

Discussing
with
Release
of
Information
with
an
important
person
in
pt’s
life
how

Education
about
how
symptoms
problem
behaviors
might
be
managed

Education
regarding
how
problem
behaviors
are
getting
in
way
of
meeting
goals
Establishing
contacts
are
necessary

ensure
treatment
plan
is
effectively
Family
sessions
with

focus
on
benefiting

pt
present

are
also
Financial

including
Medi
Cal
eligibility

For
children
document
developmental
history

including
prenatal

perinatal
events

For
children

document
school
functioning

assessment
form
requires

information
Frequency
of
symptoms

behaviors
Be
as
specific
as
possible

may
help
you
when
gathering
information

will
benefit
pt
in
receiving
necessary
services
from
sources
grooming

personal
hygiene
skills

Helping
strategize
with
pt
about
what
they
can
accomplish

assaultive
or
abusive
behavior

If
there
is

history
of

History
of
presenting
problem

when
did
symptoms
begin?
History
of
Trauma
or
Abuse

physical

sexual

emotional

Witnessing
Domestic
Violence
If
there
is
any
current
use
of
tobacco
or
caffeine
frequency
of
use
must
be
documented

Involvement
with
Public
Guardian
Administrator’s
office

involving
identified
significant
support
person
people
in
planning
of

implementation
Locating

making
referrals

providers
for
needed
services
tics

grimacing

Medical
conditions
could
be
affecting
mental
health
case
management
sessions

for
#

Memory

remote

immediate

monitoring
activities
for
necessary
follow
up

ensuring

resources

Monitoring
pt’s
progress
Monitoring

ensure
pt’s
access

services
Mood
euthymic
depressed
elevated

Community
group

as
observed
by
staff

pt
will
identify
barriers

week
in
Life
Skills
group

pt
will
process

explore
Orientation
person
place
time
Other
relevant
history
familial
relationship
issues
Past
hospitalizations
include
location
provider
date
duration
of
care
if
at
all
possible
Past
legal
involvement
with
law
enforcement
probation
or
parole
Past
or
current
involvement
with
Child
Welfare
Services
CWS
Past
use
of
illicit
substance

alcohol

tobacco

caffeine

abuse
of
prescription
drugs
Placement

Posture

slumped

relaxed

stooped

pt
will
decrease
irrational
internal
stimuli

contribute

feeling
anxious
by
weekly
pt
will
demonstrate
an
understanding
of
by
complying
with

rules
pt
will
demonstrate
effective
independent
living
skills
by
laundering
clothes
at
least

’s

pt
will
demonstrate

staff
’s
week
ability


prepare
well
rounded
balanced
pt
will
develop

attending
at
least
3
12
step
meetings
week

as
making
weekly
contact

#
2

sober

support
by
obtaining

utilizing
at
least
1

telephone
pt
will

effectively
manage
anxiety
related

h
persistent
mental
illness
by
sharing
h

pt
will
effectively
manage

impulsive
behavior
during
group
by
raising
hand
before
social
anxiety

at
least
3
symptoms
of

at
effectively
manage
symptoms
of

depression

e
g

feelings
of
hopelessness

pt
will
effectively
manage
symptoms
related


schizophrenia
e
g

responding

internal
pt
will
implement

healthy
personal
hygiene
practices

by
attending

community
peer
pt
will
improve
social
skills
by

one
difficulty
related


social
pt
will
increase
ability

concentrate


focus
on


daily
basis
by
demonstrating

increase

relationship
skills

social
interactions

communicating
pt
will
increase
stress
management
skills

reduce
irritability
by
respectfully
verbalizing
pt
will
independently

demonstrate
self
care
needs
by
showering
with
soap
shampoo
pt
will
recognize

manage

cope
with

symptoms
of
depression
e
g

low
self
esteem

reduce
feelings
of
anxiety
about
housing
by
verbalizing
thoughts
related

housing
pt
will
reduce

feelings
of
anxiety
around
not
being
understood
by
verbalizing
thoughts
pt
will
reduce
social
anxiety
related


persistent
mental
illness

emotional
reduce
social

withdrawal
by
actively
participating
in
available
treatments
social
pt
will
reduce
social

withdrawal
by
identifying

three
triggers
of

isolation
as
need

gain
approval

from
staff

by
identifying

verbalizing
at
least
one
pt
will
self
regulate
emotions

behaviors

by
requesting


speak
pt
will
understand

need
for
good
hygiene

by
reporting

practicing
3
healthy
personal
Referrals

other
providers
based
on

level
of
services
needed
Relaying
information

is
medically
necessary
from
pt

therapist

case
manager

or
Sessions
with
pt’s
family
if
they
are
identified
as
significant
support
person
people
Showing
pt
how
some
obstacle
might
be
overcome

Speech
soft
coherent
incoherent
rambling
pressured

Life
Skills
group
as
observed
by
staff
pt
will
identify
socially
week
Symptom
Reduction
group

pt
will

improve
relationship
skills

pt
will
identify

communicate
triggers
of
anger


learn
basic
hygiene

pt
will
produce

commit


daily
hygiene
pt
will
self
initiate
attending
3
independent
Twice

Symptom
Reduction

group

pt
will
identify
Under
what
circumstances
did
pt
receive
services?

Weekly
pt
will
reduce
risk
of
relapse
by
identifying
in
writing
at
least
10
triggers
e
g

Weekly
pt
will
verbalize
at
least
2
statements
of
acceptance
regarding
addiction
as
Weekly
in
Life
Skills
group
as
observed
by
staff
pt
will
identify
internal
barriers

With
regards

past
use
date
of
last
use
must
be
documented

0
times
day
1

How
did
individual
react

intervention?
1
pt

Intervention:

What
did
you
attempt

accomplish
with
individual?
1
What
safety
issues
were
present?
2
Are
there
any
safety
issues
need

be
monitored?
2
How
do
you
see
pt
moving
or
not
moving
toward
goal?
If
very
little
or
no
2
If
you
modified
intervention
how
did
you
modify
it
as
appropriate?
2
What
are
plans
for
continuing

work
with
pt?
3
Medical
Necessity:

What
are
mental
health
or
community
functions
are
still
not
3
times
day

Acknowledged
pt

Assisted
pt
in
developing


Assisted
pt
with


Brainstormed
possible
solutions


ways


Brainstormed
with
pt


Briefed
pt
parents
about

Built
rapport
by

Commended
pt

Complied
with
expectations


Did
not
respond

Consulted
with


Coordinated
with


Cued
pt

Directed
pt
pt’s
attention

Discussed
consequences
of

Engaged
pt
in


Engaged
pt
in
positive
social
interaction

Facilitated…for
an
extended
period

Intervened
with

Monitored
pt’s


Prompted
pt



Prompted
pt

comply
with
expectations

pt
modified
behavior

pt
seemed


pt’s
behavior
mimicked
paralleled
staff’s

Upon
staff’s
arrival


Used
humor



Was
able

de
escalate
4
What
is
next
step
you
are
planning

carry
out?

6
months
was

80%
of
time
during
first
month
85%
of
time
next
month…
as
reported
by
pt


hx
of


monkey

ability

complete
projects
during
Creative
Arts
groups
2
times
per
week
for
next
6
Accompanying
pt

grocery
store

assist
pt
in
practicing
acknowledged
pt
success

Activities
were
utilized

assist
pt
in
activity

addition
following
information
was
reviewed
explained
signed:
HIPAA
Privacy
Addressed
pt’s
concerns

After
report
was
made

agreed
it
was
empowering
she
was
doing
right
thing

protect
child

all
possible
angry
feelings
during
group
week
every
week
for
six
months
as
observed
by
staff

another
student

answer

anxiety
anger

anyone

appearance

appears

be
hearing
voices
as
well
as

assault

assistance
in
daily
livi
assisted
pt

Assisted
pt
in

assisted
pt
in
developing
insight
into
Assisting
with
specific
problem
area
related

such
activities
as
Activities
of
Daily
attempted

reframe
experience
in
an
empowering
way

been
receiving
services
through
agency
with
writer
for
past
year
has
made
began

being
physically
aggressive
with
younger
sister
pt
has
but
has
difficulty

by
amount
of
support
he
received
from
group
pt
quickly
identified
two
triggers:
Case
Management
is
NOT
skill
development

changes
Will
plan

monitor
pt
closely

ensure
she
has
sufficient
support

prevent
chronic
illness
Clinical
Guide—Updated
by
Quality
Management
on
2
19
2010
clinician’s
statement
she

coached
pt
on

collaborate
help
pt

overcome
obstacles
or
how
they
might
support
not
community
family
agency
pt
signed
completed
treatment
plan

Components
of
Assessment
Continued
concentrating
as
observed
by
staff

Confidentiality
Limits
of
Confidentiality
Problem
Resolution
Advance
Directives

Confronted
pt
about

confused
responding

internal
stimuli
connections
with
conservatorship’s
office
in
development
of
treatment
plan

continues

have
difficulty

coping
skills
for
anxiety
such
as
writing
going
for
walk
talking

friend
or
painting

coping
skills
for
managing
auditory
hallucinations
for
next
six
months

create
plan

avoid
triggering
situations

Current
legal
involvement
with
law
enforcement
probation
or
parole
Current
medication
prescribed
or
over
counter
For
medication


dosage

Danger

Others

describe
alternative

behavior
development
individual
group
pt
pt
will
identify
verbalize
barriers

focusing

did
not
provoke
attack

diet
changes

difficulty
focusing
in
class

Directives
Acknowledgement
of
Receipt
form
Cultural
Linguistic
needs
Provider
List

Discussed
with
pt
need

report
information

Child
Protective
Services

does
not
know
how

use
public
transportation

Domestic
Violence
Center
SADVC
where
she
reported
she
would
feel
out
of
place
Will
plan

due


Due

pt’s
severe
mental
illness
writer
is
not
referring
pt

Sexual
Assault

during
most
of
session
but
appeared
calm
prior

leaving
today

during
last

educated
pt

educated
pt
about
medications
how
they
can
reduce
symptoms
of
empowered

decrease
overall
anxiety

encouraged
pt

encouragement

endured

entirely
trusting
of

experiencing
nightmare
father
lives
out
of
state
has
had
feelings
of
feelings
of
hopelessness
by
verbalizing
how
he
she
is
feeling
during
Community
fighting
with
peers
at
school

focusing

for
next
6
months

functions
meetings
appropriately
groomed
showered
clean
clothing
teeth
brushed
deodorant
gestures
or
attempts
information
must
be
documented

getting
along

getting
up
in
morning

going

sleep
tonight

guidance

Has
history
of

has
been
hospitalized

has
cognitive
ability

learn
new
coping
skills
gain
new
insights
has
not
gotten
has
sense
of
humor
help
pt
practice
appropriate
behavior
in
help
them

helped
pt
reflect
on
progress
they
have
made
so
far
on

helping
significant
support
persons

understand
accept
pt’s
condition
herself


hid
face
behind
hair

hinder
some
area
of
improvement
in
functioning

History
of
suicidal
ideations
gestures
or
attempts
If
there
is
history
of
ideations

homeless

honestly
commit

maintaining
medication
compliance
sobriety
with
support
from
household
chores
how

obtain
bus
pass
however
pt
is
discouraged
by
however
she
was
not
hygiene
skills
as
observed
by
staff
for
next
6
months

hyperactivity
in
classroom
identify
barriers

participating
in
group
for
next
six
months

identifying
1
anxiety
provoking
trigger
for
next
6
months
as
reported
by
pt
observed
by
if
he
feels
implemented

impulsive

in
anxiety
level

in
being
able

provide
information
psychosocial
assessment
is
intervention
In
in
planning

in
session
in
past
year

inability

keep
employment
included
in
Collateral

increasing
assertive
behaviors
such
as
speaking
up
for
herself

help
pt
feel
more
indicate

indicated
she
very
much
wanted

“get
better”
have
less
anxiety
She
was
tearful
interact
with
others
peers

interactions
twice
week
for
next
6
months
as
observed
by
staff

interrupting

into
group

intrusive

intrusive
thoughts

irritability
surface
during
interactions
at
least
2
times
week
as
observed
by
staff
for

is
accessing

assist
pt
in
order

meeting
treatment
goals
are
assisting
pt
in

is
becoming
increasingly
manic

last
year

learn


least
once
week
as
observed
by
staff
for
next
6
months

Led
pt
in
practicing

level
of
grave
disability

level
of
involvement
from
pt
parent
guardian
or
linking
pts

necessary
services
little
contact
with
pt
for
several
years

living
conditions
job
employment
educational
stressors

living
skills
groups
each
week
as
reported
by
pt
observed
by
staff

MD
agrees
agreed

allot
extra
time

see

meals
as
observed
by
staff

medication
medication
compliance

modeled
appropriate
communication
skills

pt

month
as
reported
by
pt
as
observed
by
staff

months
as
observed
by
staff

most
efficient
helpful
way
mother
in
waiting
area

motivated
for
therapy
necessary
hearing
aids
needed

negative
1
positive
social
interaction
2
times
week
for
next
6
months

new
coping
skill
for
increasing
emotional
independence
each
week
for
next
6
months
as
new
seat

next
6
mos

not

not
completing
homework

number
of
clean
sober
person
as
reported
by
pt
weekly

observed
by
staff

observed
by
staff
week
every
week
for
six
months

of
pt
plans
on
behalf
of
pt
with
intent
of
benefiting
pt
on
questions
as
evidenced
by
frequent
hesitation
in
answering
questions
apologizing

ongoing
outpatient
mental
health
services
pt
mother
will
return

develop
pt
plan

ongoing
outpatient
mental
health
services
pt
will
return

develop
pt
plan

Other
paperwork

be
completed
annually:
out
in

people
places
things
as
reported
by
pt
observed
by
staff

physical
symptoms

placement
follow
up
pointed


possible
alternatives


possibly
other
children
in
future
pt
took
lead
on
formulating
goals

practiced
assertive
communication
skills

increase
interpersonal
effectiveness
practiced
effective
communication
skills

assist
pt
in
decreasing
their
Practices
Confidentiality
Limits
of
Confidentiality
Problem
Resolution
Advance
Present
use
of
illicit
substances
alcohol
tobacco
caffeine
abuse
of
prescription
drugs
Previous
mental
health
providers
include
location
provider
date
duration
of
care
if
at
prioritizing
Progressive
relaxation
techniques

provided
information

CPS
social
worker

provided
support

Provider
List
Acknowledgement
of
Receipt
form
Cultural
Linguistic
issues
were
also
psychiatrist

another
person

pt
agreed

utilize
peer
support

pt
also
reports
frequent
crying
spells

pt
answered

pt
answered
questions
with
one
word
answers

pt
began
having
great
deal
of

pt
by
initiating
time
out

pt
continues

be
disruptive
in
class

pt
denies
any
trauma
or
abuse
of
pt

pt
expressed
commitment

maintaining
sobriety

pt
expressed
she
felt
some
relief
in
discussing

pt
has

pt
has
hx
of

pt
has
been
suspended

pt
is
currently

pt
is
fearful
of
pt
Plan
Library
Continued
pt
remained
non
verbal

pt
reported
feeling
intimidated
fearful
at
first
regarding
report
however
she
pt
reported
he
was
surprised
pt
reported
she
felt
better

pt
reports
pt
reports

pt
reports
she
father
are
divorced

pt
setbacks

pt
shook
head
in
response

question

pt
skipping
out
of
office

join

pt
understands

pt
was
able

independently
identify
pt
was
initially
disruptive

pt
was
medically
cleared
then
evaluated
by
crisis
staff
placed
in
5150
hold

pt
was
unable

pt
was
willing

make
report
with

pt
wishes

attend

pt's
current
plan

pt’s
grades
have
begun
falling

pt’s
support
person
people
when
linking
pt

other
necessary
services
public

questions

re
framed
receiving
medication
services

regarding
making
report

related


relates


reported
by
pt
with
proof
of
completed
sign
in
sheet

reports
no
S
I
or
H
I

represented

represented
mother
pt
then
spent
majority
of
time
in
intake
showing
monkey
resources
at
least
3
times
week
as
observed
by
staff
for
next
6
months

Responded


reviewed
pt's
current
coping
with

risks
consequences
of

role
in
pt's
life:
routine
as
reported
by
pt
observed
by
staff

school
once
in
past

securing
an
appropriate
living
environment
select

self
soothing
exercises

session
is
an
assessment

severe
major
depressive
sx

sexual
assault

she

she
is

She
is
currently

signed

significant
support
persons:
signs
of

sleeping
well

some
small
progress
on
goals

speaking
out
loud
3
times
week
as
observed
by
staff
for
next
6
mos

staff

starting
fight

still
needs
approval
for
services

stimuli
by
verbalizing
3
coping
skills
3
times
week
as
observed
by
staff
for
next
6
months

strategically
helping
structured
task

suicide
attempts

supplies
every
month
as
reported
by
pt
observed
by
staff

sustaining
focus
on
activities

symptoms
or
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staff

the
pt
will
process


explore
Orientation


person

place

time
Other
relevant
history


familial
relationship
issues
Past
hospitalizations
include
location

provider

date



duration
of
care

if
at
all
possible
Past
legal
involvement
with
law
enforcement

probation

or
parole
Past
use
of
illicit
substance

alcohol

tobacco

caffeine



abuse
of
prescription
drugs
Placement



Posture


slumped

relaxed

stooped




Presenting
problem

including
the
current
symptoms


relevant
conditions
affecting
mental
pt
will
decrease
irrational
internal
stimuli
that
contribute
to
feeling
anxious
by
weekly
pt
will
demonstrate
an
understanding
of
Board


Care
rules
by
complying
with
the
rules
pt
will
demonstrate
effective
independent
living
skills
by
laundering
clothes
at
least

x’s
a
pt
will
demonstrate
to
staff

x’s
a
week
the
ability
to
prepare
well
rounded


balanced
pt
will
develop
a
healthy
support
system
by
attending
at
least
3
12
step
meetings
a
week
as
pt
will
develop
a
healthy
support
system
by
making
weekly
contact
with
2
sober
support
pt
will
develop
a
healthy
support
system
by
obtaining


utilizing
at
least
1
telephone
pt
will
effectively
manage
anxiety
related
to
h


persistent
mental
illness
by
sharing
h


pt
will
effectively
manage
impulsive
behavior
during
group
by
raising


hand
before
pt
will
effectively
manage
social
anxiety
by
verbalizing
at
least
3
symptoms
of
anxiety
at
pt
will
effectively
manage
symptoms
of
depression

e
g


feelings
of
hopelessness

pt
will
effectively
manage
symptoms
related
to
schizophrenia

e
g


responding
to
internal
pt
will
implement
healthy
personal
hygiene
practices
by
attending
community


peer
pt
will
improve
social
skills
by
identifying


verbalizing
one
difficulty
related
to


social
pt
will
increase


ability
to
concentrate


focus
on
a
daily
basis
by
demonstrating
the
pt
will
increase
relationship
skills
by
identifying
two
social
interactions


communicating
pt
will
increase
stress
management
skills
to
reduce
irritability
by
respectfully
verbalizing
pt
will
independently
demonstrate
self
care
needs
by
showering
with
soap


shampoo
pt
will
recognize

manage



cope
with
symptoms
of
depression

e
g


low
self
esteem


pt
will
reduce
feelings
of
anxiety
about
housing
by
verbalizing
thoughts
related
to
housing
pt
will
reduce
feelings
of
anxiety
around
not
being
understood
by
verbalizing
thoughts
pt
will
reduce
social
anxiety
related
to


persistent
mental
illness
by
identifying
emotional
pt
will
reduce
social
withdrawal
by
actively
participating
in
available
treatments
social
pt
will
reduce
social
withdrawal
by
identifying


verbalizing
three
triggers
of
isolation
as
pt
will
reduce
the
need
to
gain
approval
from
staff
by
identifying


verbalizing
at
least
one
pt
will
self
regulate
emotions


or
behaviors
by
requesting
to
speak
out
loud
in
group

x
pt
will
understand
the
need
for
good
hygiene
by
reporting


practicing
3
healthy
personal
Referrals
to
other
providers
based
on
the
level
of
services
needed
Relaying
information
that
is
medically
necessary
from
pt

therapist

case
manager

or
Relevant
conditions
affecting
mental
health


physical
stressors

relationship
factors

Relevant
family
history
abuse

neglect

substance
abuse
history

mental
health
history

Showing
pt
how
some
obstacle
might
be
overcome



Sleep


nightmares

waking
frequently

difficulty
falling
asleep

sleeping
too
little

social


leisure
skills
Social
Support
Network
for
a
child
assessment

document
caregivers

Speech


soft

coherent

incoherent

rambling

pressured




Three
times
a
week
in
Life
Skills
group


as
observed
by
staff

the
pt
will
identify
socially
Three
times
a
week
in
Symptom
Reduction
group


as
observed
by
staff

the
pt
will
To
improve
relationship
skills

pt
will
identify


communicate
triggers
of
anger


To
learn
basic
hygiene


grooming
skills

pt
will
produce


commit
to
a
daily
hygiene
To
learn
basic
hygiene


grooming
skills

pt
will
self
initiate
attending
3
independent
Twice
a
week
in
Symptom
Reduction
group


as
observed
by
staff

the
pt
will
identify
Under
what
circumstances
did
the
pt
receive
services?

Weekly

pt
will
reduce
risk
of
relapse
by
identifying
in
writing
at
least
10
triggers

e
g


Weekly

pt
will
verbalize
at
least
2
statements
of
acceptance
regarding




addiction
as
Weekly
in
Life
Skills
group


as
observed
by
staff

the
pt
will
identify
internal
barriers
to
Why
were
the
previous
services
received?
With
regards
to
past
use

date
of
last
use
must
be
documented


1

How
did
the
individual
react
to
the
intervention?
1

pt
Intervention:
What
did
you
attempt
to
accomplish
with
the
individual?
1

What
safety
issues
were
present?
2

Are
there
any
safety
issues
that
need
to
be
monitored?
2

How
do
you
see
the
pt
moving
or
not
moving
toward
the
goal?
If
very
little
or
no
2

If
you
modified
the
intervention

how
did
you
modify
it
as
appropriate?
2

What
are
the
plans
for
continuing
to
work
with


pt?
3

Medical
Necessity:
What
are
the
mental
health
or
community
functions
that
are
still
not
¾
Briefed
pt
parents




about
¾
Directed
pt
pt’s
attention
¾
pt
modified




behavior
¾
pt’s
behavior
mimicked
paralleled
staff’s
¾
Upon


staff’s
arrival


4

What
is
the
next
step
you
are
planning
to
carry
out?

6
months





was

80%
of
the
time
during
the
first
month

85%
of
the
time
the
next
month…

as
reported
by
pt

a
hx
of

a
monkey



a
store


ability
to
complete


projects
during
Creative
Arts
groups
2
times
per
week
for
the
next
6
about



about
three
months
ago


Accompanying
a
pt
to
the
grocery
store
to
assist
pt
in
practicing
addition

the
following
information
was
reviewed

explained



signed:
HIPAA
Privacy
After
the
report
was
made




agreed
that
it
was
empowering


that
she
was
doing
the
right
thing
to
protect


child


angry
feelings
during
group


x
week
every
week
for
six
months
as
observed
by
staff


another
student


answer


anxiety

anger



appearance



Appearance


older
than
stated
age

younger
than
stated
age

disheveled

clean

neat

odd
appropriate
behavior
in
the
grocery
store

as
well
as
the
Assisted
pt
in





attempted
to
reframe
the
experience
in
an
empowering
way


been
receiving
services
through


agency


with


writer
for
the
past
year



has
made
behavioral
goals
plan


being
physically
aggressive
with
younger
sister

pt
has
boredom


phone
calls
from


mother


bright
affect


by
the
amount
of
support
he
received
from
the
group

pt
quickly
identified
two
triggers:
Case
Management
is
NOT
skill
development


CBT

DBT

stress
reduction
techniques
changes

Will
plan
to
monitor
pt
closely
to
ensure
she
has
sufficient
support
to
prevent
chasing
the
elephant
around
the
sand
tray


Clarified


sought
clarification

clinician’s
statement
that
she

collaborate


help
pt
to
overcome
obstacles

or
how
they
might
support


not
Communication

coordination



referral
community

family




agency

pt
signed
completed
treatment
plan


community
resources


completing
daily
weekly
chores
for
the
next
six
months

Components
of
Assessment

Continued
Confidentiality


the
Limits
of
Confidentiality

Problem
Resolution

Advance
Directives

Confronted
pt
about





confused



responding
to
internal
stimuli
conservatorship’s
office
in
development
of
the
treatment
plan


coping
skills
for
anxiety
such
as

writing

going
for
a
walk

talking
to
a
friend

or
painting


coping
skills
for
managing
auditory
hallucinations
for
the
next
six
months

create
a
plan
to
avoid
triggering
situations


Current
legal
involvement
with
law
enforcement

probation

or
parole
Current
medication
prescribed
or
over
the
counter
For
medication

document
dosage


Currently


Danger
to
Others


decompensation


denies
any
suicidal
homicidal
ideation


describe
alternative
to




behavior
development

individual

group

pt

pt
will
identify


verbalize
barriers
to
focusing


did
not
provoke
the
attack


difficulty
concentrating


difficulty
focusing
in
class




Directives

Acknowledgement
of
Receipt
form

Cultural
Linguistic
needs


Provider
List

Discussed
with
pt
the
need
to
report


information
to
Child
Protective
Services



disruption


disruptive
behaviors


does
not
know
how
to
use
public
transportation




Domestic
Violence
Center
SADVC
where
she
reported
she
would
feel
out
of
place

Will
plan
to
Due
to
pt’s
severe
mental
illness



writer
is
not
referring
pt
to
Sexual
Assault


During
intake


during
most
of
the
session

but
appeared
calm
prior
to
leaving
today


during
the
intake


e
g



educated
pt
about
medications


how
they
can
reduce
symptoms
of
empowered


to
decrease
overall
anxiety


encouragement



Examined
benefits


consequences

experiencing
a
nightmare
explained




father
lives
out
of
state


has
had
feelings
of
hopelessness

by
verbalizing
how
he
she
is
feeling
during
Community
fighting
with
peers
at
school




flat
affect


following
the
for
the
next
6
months

functions
meetings
appropriately
groomed
showered

clean
clothing

teeth
brushed

deodorant
gestures



or
attempts



information
must
be
documented

getting
up
in
the
morning


going
to
sleep
tonight



has
cognitive
ability
to
learn
new
coping
skills


gain
new
insights
has
yielded


helping
significant
support
persons
to
understand


accept
the
pt’s
condition
hid


face
behind
hair

hinder
some
area
of
improvement
in
functioning


History
of
suicidal
ideations

gestures


or
attempts
If
there
is
a
history
of
ideations

honestly
commit
to
maintaining
medication
compliance


sobriety
with
support
from
how
to
obtain
a
bus
pass
however

pt
is
discouraged
by
hygiene
skills
as
observed
by
staff
for
the
next
6
months

hyperactivity
in
the
classroom
hypersomnia


identify
barriers
to
participating
in
group
for
the
next
six
months

implemented



impulsive




in
being
able
to
provide
information

The
psychosocial
assessment
is
the
intervention

In
in
the
past
year

inappropriate
behaviors


express
acceptable
behaviors
verbalizations
for
the
next
six
months


included
in
Collateral


indicated
that
she
very
much
wanted
to
“get
better”


have
less
anxiety

She
was
tearful
Inquired
about





interactions
twice
a
week
for
the
next
6
months
as
observed
by
staff

interrupting




into
the
group

intrusive


intrusive
thoughts


irritability
that
surface
during
interactions
at
least
2
times
a
week

as
observed
by
staff

for
the
is
accessing

to
assist
pt
in
order
to
meeting
treatment
goals
are
assisting
pt
in
the
is
becoming
increasingly
manic



last
year


least
once
a
week
as
observed
by
staff
for
the
next
6
months

Led
pt
in
practicing





level
of
grave
disability


level
of
involvement
from
the
pt

parent
guardian



or
little
contact
with
pt
for
several
years


living
conditions

job
employment
educational
stressors



made
little
eye
contact



making
a
backup
plan

manifestation


MD
agrees
agreed
to
allot
extra
time
to
see



medical
providers

social
workers


educators

medication
compliance


month
as
reported
by
pt

as
observed
by
staff

months

as
observed
by
staff

most
efficient


helpful
way
mother
in
the
waiting
area


needed


negative


1
positive
social
interaction
2
times
a
week
for
the
next
6
months

not
completing
homework


number
of
a
clean


sober
person
as
reported
by
pt
weekly

observed
by
staff


observed
by
staff


x
week
every
week
for
six
months

on
the
questions

as
evidenced
by


frequent
hesitation
in
answering
questions

apologizing

ongoing
outpatient
mental
health
services

pt


mother
will
return
to
develop
pt
plan


ongoing
outpatient
mental
health
services

pt
will
return
to
develop
pt
plan

participation



vocational
goals
must
be
documented


people

places


things

as
reported
by
pt
observed
by
staff

physical
symptoms



poor
memory


possibly
other
children
in
the
future

pt
took
the
lead
on
formulating


goals



Practices

Confidentiality


the
Limits
of
Confidentiality

Problem
Resolution

Advance
Present
use
of
illicit
substances

alcohol

tobacco

caffeine



abuse
of
prescription
drugs
Previous
mental
health
providers
include
location

provider

date



duration
of
care

if
at
progress

explain
why

Progressive
relaxation
techniques




provided
information
to
the
CPS
social
worker


provided
support


Provider
List

Acknowledgement
of
Receipt
form


Cultural
Linguistic
issues
were
also
pt
agreed
to
utilize
peer
support


pt
also
reports
frequent
crying
spells


pt
answered
questions
with
one
word
answers




pt
by
initiating
a
time
out


pt
denies
any
trauma
or
abuse
of
pt


pt
expressed
a
commitment
to
maintaining
sobriety


pt
expressed
that
she
felt
some
relief
in
discussing

pt
Plan
Library

Continued
pt
remained
non
verbal


pt
reported
feeling
intimidated


fearful
at
first
regarding
the
report

however
she
pt
reported
that
she
felt
better






pt
reports
that
she


father
are
divorced


pt
setbacks


pt
shook


head
in
response
to
the
question


pt
skipping
out
of
the
office
to
join



pt
understands



pt
was
initially
disruptive



pt
was
medically
cleared
then
evaluated
by
crisis
staff


placed
in
a
5150
hold

pt
was
willing
to
make
the
report
with



pt's
current
plan


pt’s
grades
have
begun
falling


pt’s
support
person
people
when
linking
pt
to
other
necessary
services
public



regarding
grade


school

academic
ability

achievements

any
special
education
regarding
making
the
report



reported
by
pt


with
proof
of
a
completed
sign
in
sheet

reports
no
S
I
or
H
I


represented






represented
mother

pt
then
spent
the
majority
of
the
time
in
the
intake
showing
the
monkey
resources
at
least
3
times
a
week
as
observed
by
staff
for
the
next
6
months

Responded
to





reviewed


reviewed

explained



signed:
Informing
Materials

HIPAA
Privacy
Practices

risks


consequences
of

routine
as
reported
by
pt
observed
by
staff


school
once
in
the
past

school
work
options
for
the
next
six
months

self
soothing
exercises




session
is
an
assessment



severe
major
depressive
sx


skillbuilding
tasks


sleeping
a
great
deal

sleeping
well


some
small
progress
on
goals


speaking
out
loud
3
times
a
week
as
observed
by
staff
for
the
next
6
mos

staff


staff
in
Community
group

Case
Management

Medication
Support
starting
a
fight

still
needs
approval
for
services


stimuli

by
verbalizing
3
coping
skills
3
times
a
week
as
observed
by
staff
for
the
next
6
months

structured
task


suicide
attempts


sustaining




focus
on
activities


symptoms


or
behaviors


Symptoms
as
reported
by
pt

caregiver

or
other
involved
party


a
teacher
reporting
symptoms
of
anxiety


appropriate
coping
techniques
3
times
a
week
for
the
next
6
months

taking
medication
unprompted
by
staff
for
the
next
six
months

talkative


the
attack


the
attack

In
addition



writer
explained

the
continuation
of
voices
despite



the
first
at
age
23


The
following
information
was
reviewed

the
need
for
special
accommodations


then
pointed
to
an
elephant



these
feelings


x
week
during
process
groups
as
observed
by
staff
for
six
months

These
were
utilized
to
assist
pts
in



thoughts

pt
denied
any
currently


verbally
contracted
for
safety
thoughts
associated
with
their
triggers





times
a
week
as
observed
by
staff
for
the
next
6
mos

to
call


clinician

To
learn
basic
hygiene


grooming
skills

pt
will
purchase
obtain
at
least
2
grooming
to
mother
to
indicate
that
elephant
Total
Time:
93
Min


triggers


communicating
related
feelings
2
times
per
week
as
observed
by
staff
for
the
next
6
triggers
of
paranoid
ideation
or
hypomanic
episodes
for
the
next
six
months

Twice
a
week
in
Socialization
Group


as
reported
by
staff

the
pt
will
verbalize
effective
use
cognitive
techniques


will
consult
with
psychiatrist
regarding
possible
medication
use
of
“time
outs”
as
warranted



Utilized
cognitive
tactics
to
help
pt
understand
that
she
was
the
victim


did
not
cause
utilizing
cognitive
behavioral
techniques


Validated
pt’s
point
of
view


feelings





voices


walking
out
of
class


was
fidgeting
frequently
in
chair


were
also
introduced


where
she
could
be
more
focused


less
distracted

After
the
time
out
who
are
not
identified
as
the
pt’s
support
person
people
such
as
family
members

without
prompting
from
staff
at
least

x’s
week
every
week
for
6
months
as
reported
by
pt
worthlessness



low
self
esteem

by
verbalizing
feelings
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mental
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pt
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writing
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ess
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view
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which
result
soon
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prompting
format
jewellery
worthlessness
pertinent
writing
plan
pt
understands
this
session
is
an
assessment
and
still
needs
approval
for
services.
During
intake,
pt
answered
questions
with
one
word
answers,
and
was
fidgeting
frequently
in
her
chair.
Approx.
halfway
through
the
assessment,
pt
asked
“how
much
longer
is
this
thing
going
to
take?”
and
rolled
her
eyes
when
this
writer
informed
pt
that
there
were
several
questions
still
needing
to
be
answered.

pt
understands
this
session
is
an
assessment
and
still
needs
approval
for
services.
pt
remained
non
verbal,
but
pointed
to
a
monkey
and
then
herself
to
indicate
the
monkey
represented
her,
and
then
pointed
to
an
elephant
and
to
mother
to
indicate
that
elephant
represented
mother.
pt
then
spent
the
majority
of
the
time
in
the
intake
showing
the
monkey
chasing
the
elephant
around
the
sand
tray.


pt
was
teary
eyed
while
answering
questions,
and
appeared
to
have
difficulty
focusing
on
the
questions,
as
evidenced
by
her
frequent
hesitation
in
answering
questions,
apologizing,
and
asking
this
writer
to
repeat
the
question.
While
discussing
pt’s
suicidal
or
homicidal
thoughts,
pt
denied
any
currently
and
verbally
contracted
for
safety

pt
appeared
pleased
with
the
goals
decided
upon.
pt
expressed
that
he
could
honestly
commit
to
maintaining
medication
compliance
and
sobriety
with
support
from
community,
family
and
this
agency.
pt
signed
completed
treatment
plan.

This
writer
and
pt
discussed
the
goals
of
increasing
appropriate
coping
skills
for
anxiety
(such
as,
writing,
going
for
a
walk,
talking
to
a
friend,
or
painting)
and
increasing
assertive
behaviors
(such
as
speaking
up
for
herself)
to
help
pt
feel
more
empowered
and
to
decrease
overall
anxiety.

pt
reported
feeling
intimidated
and
fearful
at
first
regarding
the
report,
however
she
agreed
that
it
was
empowering
and
that
she
was
doing
the
right
thing
to
protect
her
child
and
possibly
other
children
in
the
future.
pt
took
the
lead
on
formulating
her
goals,
and
indicated
that
she
very
much
wanted
to
“get
better”
and
have
less
anxiety.
She
was
tearful
during
most
of
the
session,
but
appeared
calm
prior
to
leaving
today.

Utilized
cognitive
tactics
to
help
pt
understand
that
she
was
the
victim
and
did
not
cause
the
attack.
In
addition,
this
writer
explained
Post
Traumatic
Stress
Disorder
(PTSD)
manifestation.

pt
expressed
that
she
felt
some
relief
in
discussing
the
attack,
however
she
was
not
entirely
trusting
of
clinician’s
statement
that
she
did
not
provoke
the
attack.
pt
is
fearful
of
going
to
sleep
tonight
and
experiencing
a
nightmare
pt
reported
that
she
felt
better,
and
this
writer
observed
pt
skipping
out
of
the
office
to
join
her
mother
in
the
waiting
area.


pt
identified
their
own
triggers,
spent
some
time
processing
through
feelings
and
thoughts
associated
with
their
triggers,
and,
utilizing
cognitive
behavioral
techniques,
began
to
create
a
plan
to
avoid
triggering
situations.

pt
expressed
a
commitment
to
maintaining
sobriety,
however,
pt
is
discouraged
by
the
continuation
of
voices
despite
his
medication
compliance.
pt
reported
he
was
surprised
by
the
amount
of
support
he
received
from
the
group.
pt
quickly
identified
two
triggers:
boredom
and
phone
calls
from
his
mother.

pt
agreed
to
utilize
peer
support,
community
resources,
or
to
call
this
clinician
if
he
feels
his
condition
is
deteriorating.
Clinician
and
pt
will
consult
with
psychiatrist
regarding
voices.

pt
was
initially
disruptive
and
intrusive;
interrupting
both
presenters
and
violating
other
participants’
space
by
taking
away
their
cards
and
talking
over
her
peers.
This
writer
assisted
pt
by
initiating
a
time-out,
then
reintegrating
pt
into
the
group
by
strategically
helping
pt
select
a
new
seat
where
she
could
be
more
focused
and
less
distracted.
After
the
time-out
and
reintegration,
pt
proceeded
to
engage
successfully
in
the
activity
without
further
disruption.


pt
appreciative
of
the
intervention
and
reports
a
drop
in
anxiety
level.
appeared
disheveled,
confused,
and
responding
to
internal
stimuli
pt
was
medically
cleared
then
evaluated
by
crisis
staff
and
placed
in
a
5150
hold

¾
pt’s
behavior
mimicked/paralleled
staff’s
¾
pt
modified
his/her
behavior
¾
Responded
age-appropriately
¾
Was
able
to
de-escalate
Did
you
spend
time
talking
to
the
pt
about
how
they’re
doing,
why
they’re
cancelling,
etc?
That
time
would
be
billable,
particularly
if
you’re
working
on
something
like
importance
of
maintaining
scheduled
appointments
for
treatment
or
working
on
treatment
planning
for
future
sessions.

Is
it
possible
to
move
a
later
pt
into
an
earlier
spot
and
possibly
reschedule
this
pt
for
later
in
the
week?
That
will
help
increase
your
billing
as
well.

If
you
still
have
time
leftover,
try
to
contact
collateral
or
case
management
supports
on
behalf
of
the
pt.
has
cognitive
ability
to
learn
new
coping
skills
and
gain
new
insights
significant
support
person(s):

spiritual
beliefs,
family
support,
motivation,
intelligence
and
good
Present
use
of
illicit
substances,
alcohol,
tobacco,
caffeine,
and
abuse
of
prescription
drugs

Past
use
of
illicit
substance,
alcohol,
tobacco,
caffeine,
and
abuse
of
prescription
drugs

If
there
is
any
current
use
of
tobacco
or
caffeine,
frequency
of
use
must
be
documented.

With
regards
to
past
use,
date
of
last
use
must
be
documented.

History
of
suicidal
ideations,
gestures
and/or
attempts
(If
there
is
a
history
of
ideations,
gestures,
and/or
attempts,
this
information
must
be
documented).

Current
assessment
of
suicidal
ideations,
gestures,
and/or
attempts
and
documentation
as
to
what
information
that
assessment
has
yielded.

History
of
assaultive
or
abusive
behavior
(If
there
is
a
history
of
this
behavior,
the
information
must
be
documented.)

Current
assessment
of
assault
risk
and
documentation
as
to
what
information
that
assessment
has
yielded.

level
of
involvement
from
the
pt,
parent/guardian,
and/or
conservatorship’s
office
in
development
of
the
treatment
plan.

untitled
project
3.bbprojectd:
kelliclarktherapy.bbprojectsettings
project.bbprojectdata
Scratchpad.txt
Unix
Worksheet.worksheet
symptoms
related

anxiety
related
her
persistent
mental
illness
by
sharing
h
he
appeared
pleased
the
goals
decided
upon
expressed
that
he
coul
appreciative
of
the
intervention
reports

drop?
at
least
1

at
least
3
by
obtaining
decrease
irrational
internal
stimuli
that
contribute
feeling
anxious
by
week
demonstrate

understanding
of
rules
by
complying
the
rule
demonstrate
effective
independent
living
skills
by
laundering
clothes
at
least
x

demonstrate
staff
x

week
the
ability
prepare
well
rounded
balance
develop

healthy
support
system
develop

healthy
support
system
by
effectively
manage
identified

triggers

spent
some
time

processing
feelings
implement
healthy
personal
hygiene
practices
by
attending
community
pee
improve
relationship
skills

identify
communicate
triggers
of
anger
improve
social
skills
by
identifying
verbalizing
one
difficulty
related
his
social
impulsive
behavior
during
group
by
raising
his
hand
before
increase
her
ability
to
concentrate
focus
on
a
daily
basis
by
demonstrating
th
increase
relationship
skills
by
identifying
two
social
interactions
communication
increase
stress
management
skills
reduce
irritability
by
respectfully
verbalizing
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practices
risks
consequences
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role
in
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life
role
model
routine
as
reported
by
observed
by
staff
run
ou
scar
school
once
in
the
past
6
months
was
due
starting

fight
another
student
school
work
options
for
the
next
six
months
securing
housing
or
placement
select

new
seat
where
she
could
be
more
focused
less
distracted
after
the
time
ou
self
report
session
was
interactive
because
of
the
utilization
of
sand
tray

assist
sessions

family
if
they
are
identified
as
significant
support
person
people
set
clear
severe
major
depressive
sx
sexual
assault
she
endured
she
has
not
told
anyone
about
assault
she
is
currently
shook
her
head
in
response
the
question
showing
how
some
obstacle
might
be
overcome
how
obtain

bus
pas
siblin
significant
support
persons
signs
of
skillbuilding
tasks
skipping
out
of
the
office
to
join
her
mother
in
the
waiting
area
sleep
disturbance
sleeping

great
deal
sleeping
too
little
sleeping
well
is
becoming
increasingly
manic
appears
be
hearing
voice
smile
social
leisure
skill
social
support
network
social
worker
after
the
report
was
made
writer
processed
the
experience
soiled
cloth
some
small
progress
on
goals
speaking
out
loud
3
times
a
week
as
observed
by
staff
for
the
next
6
mos
speech
soft
coherent
incoherent
rambling
pressured
spiritual
beliefs
family
support
motivation
intelligence
goo
staff
staff
in
community
group
case
management
medication
support
start
time:
2:01
p
stimuli
by
verbalizing
3
coping
skills
3
times
a
week
as
observed
by
staff
for
the
next
6
months
substance
abuse
history
suggest
suicidal
or
homicidal
suicide
attempts
supplies
every
month
as
reported
by
observed
by
staff
support
service
surgerie
sustaining
his
her
focus
on
activities
symptom
reduction
group
living
skills
group
providing
feedback
fro
symptoms
as
reported
by
caregiver
or
other
involved
party

teacher
reporting
symptoms
of
anxiety
appropriate
coping
techniques
3
times
a
week
for
the
next
6
months
taking
medication
unprompted
by
staff
for
the
next
six
months
taking
walk
tattoo
the
attack
in
addition
writer
explained
post
traumatic
stress
disorder
ptsd
the
continuation
of
voices
despite
his
medication
compliance
reported
he
was
surprised
the
first
at
age
23
the
following
information
was
reviewed
the
goal
that
is
being
focused
on
today
the
psychosocial
assessment
is
the
intervention
in
addition
the
following
information
wa
their
priority
these
feelings
x
week
during
process
groups
as
observed
by
staff
for
six
months
these
were
utilized
assist
pts
in
thoughts
associated
their
triggers
utilizing
cognitive
behavioral
techniques
began
thoughts
denied
any
currently
verbally
contracted
for
safety
three
times
three
times
a
week
in
life
skills
group
as
observed
by
staff
identify
social
three
times
a
week
in
symptom
reduction
group
as
observed
by
staff
the
time
out
time
see
times

week
as
observed
by
staff
for
the
next
6
mos
total
time:
93
min
tracking
worked

on
triggers
communicating
related
feelings
2
times
per
week
as
observed
by
staff
for
the
next

triggers
of
paranoid
ideation
or
hypomanic
episodes
for
the
next
six
months
twice

week
in
socialization
group
as
reported
by
staff
the

verbalize
effective
twice
a
week
in
symptom
reduction
group
as
observed
by
staff
the

identifier
under
what
circumstances
did
receive
services?
understands
session
is

assessment
still
needs
approval
for
services
unshave
upon
staff
arrival
use
cognitive
techniques

consult
psychiatrist
regarding
possible
medication
use
of
time
outs
as
warranted
needed
activities
were
utilized
assist
pts
i
used
empathy
understand
used
open
ended
questions
explore
usefulness
of
utilized

structured
card
game
that
required
participants
maintain
focus
utilized
cognitive
tactics
help
understand
that
she
was
the
victim
did
not
cause
utilized
mindfulness
techniques
utilized
motivational
interviewing
technique
validated

point
of
view
feelings
vocational
goals
waking
frequently
wants
vs
needs
was
able
was
able
de
escalate
was
able
independently
identify
was
initially
disruptive
intrusive
interrupting
both
presenters
violating
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was
medically
cleared
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evaluated
by
crisis
staff
placed
in

5150
hold
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mostly
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unable
was
willing
make
the
report

writer
assistance
writer
called
cps
weekly

reduce
risk
of
relapse
by
identifying
in
writing
at
least
10
triggers
weekly

verbalize
at
least
2
statements
of
acceptance
regarding
his
her
addiction

weekly
in
life
skills
group
as
observed
by
staff
identify
internal
barriers
weight
loss
approx
were
also
introduced
what
information
that
assessment
has
yielded
when
did
the
symptoms
begin
when
has
difficulty
making
decision
which
result
in
while
discussing
while
homeless
last
year
who
are
not
identified
as
the

support
person
people
such
as
family
members
who
indicated
why
were
the
previous
services
received
wishes
without
prompting
from
staff
at
least
x
week
every
week
for
6
months
as
reported
by
work
on
worthlessness
low
self
esteem
by
verbalizing
feelings
related
his
her
mental
illness
would
also
be
pertinent
information
wound
writer
writer

discussed
the
goals
of
increasing
appropriate
writing
the
plan
goals
x
week
every
week
for
six
months
as
observed
b
x
week
every
week
for
six
months
as
observed
by
staff

Accessing
services
necessary
to
secure
placement



Accompanying
a
pt
in
public
to
model




Affect


appropriate

rich

flat

restricted

blunted





Allergies
to
medication

food

seasonal





Arrest
History
when


what

At
least
twice
a
week
for
the
next
6
months
during
case
management
meetings

plan

Attitude


cooperative

uncooperative

evasive





Behavior


overactive

under
active

fidgety

distant

childlike
for
an
adult

friendly


Behaviors
as
reported
by
pt

caregiver

or
other
involved
party

Characteristics
of
thoughts


illusions

paranoia

grandiosity

hallucinations

delusions


consulting
with
other
necessary
professional
entities
who
are
not
identified
as
the

Current
assessment
of
assault
risk


documentation
as
to
what
information
that
assessment

Current
assessment
of
suicidal
ideations

gestures



or
attempts


documentation
as
to

Discussing
with
Release
of
Information
with
an
important
person
in
pt’s
life
how
to

Education
about
how
symptoms
problem
behaviors
might
be
managed




Family
sessions
with
the
focus
on
benefiting
the
pt

with
the
pt
present

are
also

Financial

including
Medi
Cal
eligibility


For
children

document
developmental
history

including
prenatal


perinatal
events


For
children

document
school
functioning

The
assessment
form
requires
that
information

Frequency
of
symptoms


behaviors
Be
as
specific
as
possible



may
help
you
when

grooming


personal
hygiene
skills


Helping
strategize
with
pt
about
what
they
can
accomplish





History
of
assaultive
or
abusive
behavior
If
there
is
a
history
of


behavior

the

History
of
presenting
problem


when
did
the
symptoms
begin?

History
of
Trauma
or
Abuse
physical

sexual

emotional

Witnessing
Domestic
Violence

Identifying
obstacles




If
completing
a
child’s
assessment

also
document
the
response
of
the
caregivers
to
the

If
there
is
any
current
use
of
tobacco
or
caffeine

frequency
of
use
must
be
documented


Involvement
with
Public
Guardian
Administrator’s
office


involving
identified
significant
support
person
people
in
planning
of


implementation

Locating




Mannerisms


gestures

tics

grimacing






Meeting

case
management
sessions

pt


x
week
every
week
for
six
months
as
observed
by

Memory


remote

recent

immediate





monitoring
the
activities
for
necessary
follow
up


ensuring
that
resources
that
pt

Mood


euthymic

depressed

elevated





Once
a
week
in
Community
group


as
observed
by
staff

the
pt
will
identify
barriers
to

Once
a
week
in
Life
Skills
group


as
observed
by
staff

the
pt
will
process


explore

Orientation


person

place

time

Other
relevant
history


familial
relationship
issues

Past
hospitalizations
include
location

provider

date



duration
of
care

if
at
all
possible

Past
legal
involvement
with
law
enforcement

probation

or
parole

Past
use
of
illicit
substance

alcohol

tobacco

caffeine



abuse
of
prescription
drugs

Placement




Posture


slumped

relaxed

stooped





Presenting
problem

including
the
current
symptoms


relevant
conditions
affecting
mental

pt
will
demonstrate
an
understanding
of
Board


Care
rules
by
complying
with
the
rules

pt
will
demonstrate
effective
independent
living
skills
by
laundering
clothes
at
least

x’s
a

pt
will
demonstrate
to
staff

x’s
a
week
the
ability
to
prepare
well
rounded


balanced

pt
will
develop
a
healthy
support
system
by
attending
at
least
3
12
step
meetings
a
week
as

pt
will
develop
a
healthy
support
system
by
obtaining


utilizing
at
least
1
telephone

pt
will
effectively
manage
anxiety
related
to
h


persistent
mental
illness
by
sharing
h



pt
will
effectively
manage
impulsive
behavior
during
group
by
raising


hand
before

pt
will
effectively
manage
symptoms
of
depression

e
g


feelings
of
hopelessness


pt
will
effectively
manage
symptoms
related
to
schizophrenia

e
g


responding
to
internal

pt
will
implement
healthy
personal
hygiene
practices
by
attending
community


peer

pt
will
improve
social
skills
by
identifying


verbalizing
one
difficulty
related
to


social

pt
will
increase


ability
to
concentrate


focus
on
a
daily
basis
by
demonstrating
the

pt
will
increase
relationship
skills
by
identifying
two
social
interactions


communicating

pt
will
independently
demonstrate
self
care
needs
by
showering
with
soap


shampoo

pt
will
recognize

manage



cope
with
symptoms
of
depression

e
g


low
self
esteem



pt
will
reduce
social
anxiety
related
to


persistent
mental
illness
by
identifying
emotional

pt
will
reduce
social
withdrawal
by
actively
participating
in
available
treatments
social

pt
will
reduce
social
withdrawal
by
identifying


verbalizing
three
triggers
of
isolation
as

pt
will
reduce
the
need
to
gain
approval
from
staff
by
identifying


verbalizing
at
least
one

pt
will
self
regulate
emotions


or
behaviors
by
requesting
to
speak
out
loud
in
group

x

pt
will
understand
the
need
for
good
hygiene
by
reporting


practicing
3
healthy
personal

Relaying
information
that
is
medically
necessary
from
pt

therapist

case
manager

or

Relevant
conditions
affecting
mental
health


physical
stressors

relationship
factors


Relevant
family
history
abuse

neglect

substance
abuse
history

mental
health
history


Sessions
with
pt’s
family
if
they
are
identified
as
significant
support
person
people

Showing
pt
how
some
obstacle
might
be
overcome




Sleep


nightmares

waking
frequently

difficulty
falling
asleep

sleeping
too
little


social


leisure
skills

Social
Support
Network
for
a
child
assessment

document
caregivers


Speech


soft

coherent

incoherent

rambling

pressured





Three
times
a
week
in
Life
Skills
group


as
observed
by
staff

the
pt
will
identify
socially

Three
times
a
week
in
Symptom
Reduction
group


as
observed
by
staff

the
pt
will

To
improve
relationship
skills

pt
will
identify


communicate
triggers
of
anger



To
learn
basic
hygiene


grooming
skills

pt
will
produce


commit
to
a
daily
hygiene

To
learn
basic
hygiene


grooming
skills

pt
will
self
initiate
attending
3
independent

Twice
a
week
in
Symptom
Reduction
group


as
observed
by
staff

the
pt
will
identify

Weekly

pt
will
reduce
risk
of
relapse
by
identifying
in
writing
at
least
10
triggers

e
g



Weekly

pt
will
verbalize
at
least
2
statements
of
acceptance
regarding




addiction
as

Weekly
in
Life
Skills
group


as
observed
by
staff

the
pt
will
identify
internal
barriers
to

With
regards
to
past
use

date
of
last
use
must
be
documented




3



ability




agreed

utilize
peer
support



also
reports



an
understanding
of


answered
questions
with
one
word
answers



at
least


attend



began
having
great
deal
of



benefit
in
receiving
necessary
services
from
sources


by
initiating
time
out



continues

disruptive
in
class



denies
any
trauma
or
abuse
of



effective



effectively
manage
symptoms
related




expressed


felt
some
relief
in
discussing



expressed
commitment

around
maintaining
sobriety



frequent
crying
spells



has
hx
of



identify
barriers



implement



improve
social
skills
by


increase
ability


increase
stress
management
skills




independent
living
skills



independently



irrational
internal
stimuli



irritability



is
fearful
of


laundering
clothes



make
report
with



presents
with



process



produce



recognize



reduce
social
anxiety
by
initiating
3
social
interactions
per
week
as
observed
by




reported


felt
better



reported
feeling
intimidated
fearful
at
first
regarding
report
however




reports


father
are
divorced



self
initiate
attending



self
regulate
emotions



shook
head
in
response

question



skipping
out
of
office

join



support
person
people
when
linking

other
necessary
services


understand



understands



was
able
to
independently
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was
initially
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was
medically
cleared
then
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by
crisis
placed
in
5150
hold



was
willing




wishes



Acknowledged



appeared
pleased
with
goals
decided
upon
expressed
he
could

appreciative
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as




As
part
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skills
improve
self
awareness
by
reporting

1

assist
in
achieving
goals

Assisted
in
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Assisted
with

Assisted
with


behavior
mimicked
paralleled



Brainstormed
with


Commended



comply
with
expectations

consult
with


Cued



increase
motivation

change

is
#
year
old
<race>
<sex>
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purchase
obtain
at
least
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proceeded

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successfully
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activity
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further

Prompted



reports
drop

session
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sand
tray
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assist



tracking
Worked
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was
assessed

at
low
risk


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teary
eyed
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was
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discuss

While
discussing
suicidal
or
homicidal

writer
discussed
goals
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appropriate

writer
informed

2
How
do
you
see
moving
or
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very
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What
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?
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Accompanying

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Acknowledgement
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Receipt
form

Activities
were
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are

as
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assist
in
assist
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order


assist
in
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assist
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Assisted
in

assisting
in

attempted


barriers


Behaviors
as
reported
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being
physically
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with

by
amount

changes

Child
Protective
Services

coached
on

collaborate

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Linguistic
issues

Cultural
Linguistic
needs

development

Directives

Discussed
with

Discussing
with
Release
of
Information
with
an
important
person
in
life
how

during
first
month
8
educated
about
medications
how
they
can
reduce
symptoms
of
Education
about
how
symptoms
problem
behaviors
might
managed

ensure


has
sufficient
support


explore


express
acceptable
behaviors

family

family
agency

for
next
six
months

gestures
or
attempts
information
must
documented

grocery
store


he
received

help

overcome
obstacles

help
feel
more
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practice
appropriate
behavior
in
help
understand


was
victim
did
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helped
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on
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they
have
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so
far
on

helping
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support
persons

understand
accept
condition
Helping
strategize
with
about
what
they
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how
some
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might
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however
is
discouraged
by
identified
as

identifying
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anxiety
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trigger

in
public


inappropriate
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increasing
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individual

is
accessing


is
medically
necessary

Led
in
practicing

level
of
involvement
from
parent
guardian
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with
for
several
years

living
skills
groups
each
week
as
reported
by
observed
by

meeting
treatment
goals

Met
with

model

modeled
appropriate
communication
skills


monitor
closely


Monitoring

ensure
access

services
month
as
reported
by
as
observed
by

need


next
month…

number
of
clean
sober
person
as
reported
by
weekly

observed
by
of
plans
of
support

on
behalf
of
with
intent
of
benefiting


ongoing
outpatient
mental
health
services
mother
return

develop
plan

ongoing
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mental
health
services
return

develop
plan

or
how
they
might

people
as
reported
by


people
places
things
as
reported
by
observed
by

plan


possibly
other
children
in
future
took
lead
on
formulating
goals

practiced
effective
communication
skills

assist
in
decreasing
their
Provider
List

quickly

reduce
risk
of
relapse
by
identifying
in
writing
at
least
10
triggers


reframe
experience
in
an
empowering
way

report
information


reported
by
with
proof
of
completed
sign
in
sheet

represented
mother
then
spent
majority
of
time
in
intake
showing
monkey
reviewed
current
coping
with

routine
as
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g



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why
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discussed
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appropriate


'93stop
breathe
think
'94

0
timesday

80%
of
the
time
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first
month
85%
of
time
next
month
as
reported


ability
to
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times
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signed:
hipaa
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being
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sister
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bizarrely
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boredom
phone
calls
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mother


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brainstormed


brainstorm
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brief
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briefed
parents
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about

bright
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skill
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causing
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dbt
stress
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chasing
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clarified


clarified
sought
clarification


clinical
guide
'97updated
quality
management
2192010

clothes

coached


collaborate
overcome
obstacles
or
how
might
support
not

commended


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as
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andlimits
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about


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stimuli

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comments


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development
of
treatment
plan


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continually


continues
have
difficulty
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along
younger
sister


contracted


coordinated


coping
skills
anxiety
such
as
writing
going
for
walk
talking
to
friend
or
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managing
auditory
hallucinations
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next
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months


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acknowledgement
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child
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md
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'93upswing
'94

during
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answered
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statement
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established


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meetings
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'94
rolled
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asked

'93how
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psychosocial
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speaking
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'93get
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have
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months
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nextmos


nightmares


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'92
space
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:

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eteacher
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'93timeouts
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about
...

Validated
pt’s
point
of
view
/
feelings
...

Examined
benefits
/
consequences

Inquired
about
...

Questioned
(openly)

Led
pt
in
practicing
...

Responded
to
...

used
open-ended
questions
to
explore
pt
pt
setbacks,

risks
and
consequences
of

anxiety,
anger,
etc
educated
pt
about
medications
and
how
they
can
reduce
symptoms
of
CBT,
DBT,
stress
reduction
(techniques)
pt's
current
plan,

and

Result - Copy and paste this output: