Brief structured counseling note with SP macros for name
{client_first_name}[select name="gender_ID" value="| (they)| (she)| (he)| (XXXXXX)|"] arrived [select name="on_time" value="on time|5-10 minutes late| more than 10 minutes late|xxxxxx"] for [select name="scheduled_crisis" value="scheduled follow up|crisis|xxxxxx"] session. This session is [select name="placeofservice" cols="40" value=" in person.|via live telehealth with the client at their home in WI.|via live telehealth with the client confirmed to be in WI."] Obtained consent to treat using this modality. This session was medically necessary to address symptoms, improve functioning [checkbox name="preventdecomp" value=" prevent decompensation"][checkbox name="reducesx" value=" reduce symptoms"][checkbox name="maintprogr" value=" maintain progress"][checkbox name="prevhighterneed" value=" prevent necessity for higher level of care"]. - [checkbox name="mednecc1" value="Medical Necessity of 90837 or Extended Session: "][checkbox name="medical" value="Complex Treatment Issues Addressed|Trauma Issues Addressed Required Time for Containment|Safety Concerns Requiring Additional Time|Prevention of Increasing Frequency of Sessions|Planning of Homework and Skills to Practice Between Sessions|Prevention of Need for Higher Level of Care"].[textarea name="variable_5" default=" "] [checkbox name="interactive Complexity" value="**NOTE Interactive Complexity: Language Interpretation**"] - {client_first_name} reported [checkbox value="increased|decreased|no significant change in|variable"] symptoms of [checkbox value="anxiety|depression|poor impulse control|agitation/restlessness|hypervigilance|fatigue/low energy|trouble staying or falling asleep|intrusive/obsessive thoughts|grief|isolation/loneliness|anger|self-harm|flashbacks |dissociation"].[textarea name="variable_1" default=" "] {client_first_name} [select name="indicate_demonstrate" value="indicated and demonstrated|indicated|demonstrated"] [checkbox value="significant|some|maintained|no significant change regarding|ongoing|regression of"] progress in [checkbox value="mindfulness|emotional regulation|assertion of healthy boundaries|utilizing assertive communication skills|use of cognitive coping skills outside of sessions|overall reduced anxiety|overall reduced depression|reduced avoidance of triggers/stressors|increased self care"][textarea name="variable_2" default=" "] since the last session. Session focus: [checkbox name="focus" value="history/background|stressors/coping strategies|affect regulation|family relationships|identity/roles|work/school issues|substance use|trauma|peer relationships|self-image/self-esteem|marital issues|relationship issues|parenting |attachment|sexual issues|grief/loss |health issues|domestic violence|racial identity|cultural identity|boundaries"]. [textarea name="variable_299" default=" "] - Current Functional Impairments [checkbox name="impairments" value="Daily Tasks/Responsibilities|Social|Work/School|Intimate Relationships"].[textarea name="variable_4" default=" "] Clinical Interventions used: Psychoeducation regarding symptom-management and skill building, [checkbox name="Interventions" value="trauma focused CBT|CBT (cognitive challenging, cognitive refocusing, cognitive reframing)|rapport building|EMDR|DBT|play/art therapy techniques (Note: interactive complexity-use of play/art equipment)|grief processing|parent education|coping skills|attachment therapy techniques|solution-focused|mindfulness|Family Systems/Dynamics|Internal Family Systems|parts work|communication skills work|DBT skills work (distress tolerance, interpersonal effectiveness)|goal setting|discussing treatment and treatment plan"].[textarea name="variable_3" default=" "] - [select name="hworkleader" value="{client_first_name} is encouraged to: |Between sessions, {client_first_name} agrees to work on the following: |Homework: "] [checkbox name="homework" value="Reflect on psychoeducation topics/materials covered in today's session|Engage in journaling/reflective note taking as discussed in session|Create daily routine to encourage self care, behavioral activation, and organization|Consistently commit to daily routine/behavioral activation schedule|Establish healthy boundaries with friends/family using techniques discussed and roleplayed during session|Practice healthy communication skills with family/friends, as outlined in communication skills work completed in session|Utilize CBT skills (reframing/challenging/replacing negative thoughts)|Engage in self directed exposure therapy/incremental training around specific anxieties as discussed in session|Decrease catastrophic thinking by engaging in behavioral experiments|Engage in mindfulness/stress reduction techniques as practiced in therapy (deep breathing, meditation, guided imagery)|Experiment with at least one new self care activity this week|Practice distress tolerance skills as rehearsed in therapy|Implement coping skills consistently when dysregulated|Track mood and triggers for mood fluctuations|Follow safety plan if in crisis|Track success and progress toward goals|Devise a regular and adequate eating schedule, a pattern of adequate sleep and relaxation, as well as regular cardiovascular exercise|and reflect in journal/planner|and track progress"].[textarea name="variable_6" default=" "] {client_first_name} would benefit from [checkbox value="continuing psychotherapy|engaging in recovery meetings|continuing recovery meetings|engaging in recovery coaching|continuing recovery coaching|engaging in IOP|engaging in a support group|continuing support group|engaging in family therapy|continuing family therapy|enhanced psychosocial supports|increasing self-care|engaging in psychiatric intervention|continuing psychiatric intervention|engaging in higher level of care"].[textarea default=" "rows="2"] Next appointment [select name="scheduling" value="is scheduled for {client_next_appointment_date} at {client_next_appointment_time}.|is scheduled for 1 week out.|is scheduled for 2 weeks out.|is scheduled for 3 weeks out.|is scheduled for 1 month out.|is scheduled for: |to be scheduled by {client_first_name}.|to be scheduled by guardian.|to be scheduled after assessment for higher level of care and completion of recommended treatment.|"][textarea name="ending_text" default=" "]
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.72, 32 form elements, 67 boilerplate words, 9 text areas, 16 checkboxes, 7 drop downs, 139 total clicks
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