The Client 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"].
The Client indicated and/or demonstrated [checkbox value="significant |some |maintained |no significant change regarding |ongoing |regression of"] progress in areas of [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"] 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 |Relationship Issues |Parenting |Attachment |Sexual Issues |Grief/Loss |Health Issues |Domestic Violence |Racial Identity/Trauma |Boundary Setting"]
Clinical Interventions used [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 |psychoeducation regarding symptom-management and skill building| parent education |coping skills |attachment therapy techniques |solution-focused |mindfulness |Family Systems/Dynamics| Note: interactive complexity- language interpretation"].
Current Functioning Impairments [checkbox name="impairments" value="Daily Tasks/Responsibilities |Social |Work/School |Intimate Relationships "].
[checkbox name="medical" value="Medical Necessity of 90837 or Extended Session-Complex Treatment Issues Addressed| Medical Necessity of 90837 or Extended Session-Trauma Issues Addressed Required Time for Containment| Medical Necessity of 90837 or Extended Session-Safety Concerns Requiring Additional Time| Medical Necessity of 90837 or Extended Session-Prevention of Increasing Frequency of Sessions| Medical Necessity of 90837 or Extended Session-Planning of Homework and Skills to Practice Between Sessions| Medical Necessity of 90837 or Extended Session-Prevention of Need for Higher Level of Care"].
[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 |Discuss healthy communication skills with family/friends, as outlined in communication skills work complete 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 and tracking progress |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 and reflect in journal/planner |Practice distress tolerance skills as rehearsed in therapy |Implement coping skills consistently when dysregulated |Tracking mood, and triggers for mood fluctuations | Following safety plan if in crisis |Track success and progress toward goals |Client will devise a regular and adequate eating schedule, a pattern of adequate sleep and relaxation, as well as regular cardiovascular exercise"].
The next appointment is scheduled for [date name="variable_1" default="today"]
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