DAP in-home adolescent 2.0

Psychiatry & Psychology
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MHP [select name="duh" value="met face-to-face with|met via Zoom with|spoke via phone with|emailed|had text (SMS) exchange with"] [select name="Who" value="the youth|parent|family|MHCC|social worker|grandparent(guardian)|MHCC, youth guardian, youth|treatment team|other MHP( )"] for [select name="dooo" value="an individual session|scheduling services|a family session| a family and then an individual session|a discussion about case details|an initial pre-admission meeting|request_____|treatment team meeting|IEP meeting"] [select name="variable_3" value="at the youth's home|at school|at a public park| in a community and also a home setting"].
[checkbox name="COVID19" value=" The youth denied any exposure to, or symptoms of COVID-19 (fever, aches, coughing, etc) before the start of this session. "]


MHP:[textarea name="variable_1" default=" "][checkbox name="variable_14" value="assessed thought process and reasons for symptoms of anxiety |explored triggers/situations that cause increased anxiety |created list of -----|talked about benefits of taking medication to decrease anxiety symptoms encouraged youth reading on roots of social anxiety|used games and play to build rapport |explored changes in symptoms of anxiety with youth|highlighted youths strengths|taught relaxation skills to assist with reduction in anxiety symptoms|created an anxiety exposure hierarchy|utilized relaxation homework to reinforced skills learned |assisted to analyze fears associated with anxiety |helped develop insight into avoidance behaviors |encouraged identifying source of distorted thoughts|validated youths thoughts and concerns |identified situations that are anxiety provoking |taught/practiced problem-solving strategies |Encouraged routine use of strategies |assisted to identify coping skills that have helped in the past |validated/reinforced use of coping skills|assessed behaviors and thoughts that cause distress|explored interpersonal skills|explored trauma/abuse from past that cause reoccurring distress|validated distress and difficulties|encouraged awareness of emotional states|explored risky behaviors/selfinjurious behaviors when distressed |identified positive behaviors to increase|encouraged the practice of using coping skills when distressed |assisted to identify and work through therapy interfering behaviors |processed benefits/effectiveness of medication |encouraged play/exploration|clarified expectations|reinforced use of positive self-talk |assisted to identify and explore triggers|gave psychoeducation on mental health disorders|Facilitated/explored understanding of risk factors|reviewed effects of negative peer influences |encouraged exercise and social activities|assisted to identify social support system|provided space and validation for the youth to explore-----|reframed/ explored effects of negative self-talk|assessed stress management skills|assisted to identify family dynamic patterns|explored effects of childhood experiences that cause distress|encouraged healthy expression of feelings|encouraged use of journaling|encouraged outside reading on trauma |explored how trauma impacts parenting patterns |created an exposure hierarchy|assisted to identify and explore benefits of forgiveness|explored history of dependency on others|identified how fear of disappointing others affects functioning |assisted to identify and list positive aspects of self |assigned positive affirmations |assisted to identify how distorted thoughts affect understanding |assisted to identify and explore fears of independence|identified ways to increase independence|taught and reinforced positive self-talk|explored issues around codependency|discussed the signs of an abusive partner|educated on benefits of assertiveness skills|taught/practice assertiveness skills|assisted to identify and list steps toward independence |identified needs in relationships|taught about healthy boundaries|encouraged activity scheduling as a mental health tool|encouraged positive decision making|assessed history of depressed mood|assisted to identify symptoms of depression|assisted to identify what behaviors are associated with youths depression|assessed level of risk|assessed suicide potential and risk |taught and assisted to identify coping skills to decrease suicide risks |assisted to identify patterns of depression|encouraged journaling feelings as coping skill |assisted to identify support system|encouraged positive self-talk|explored issues of unresolved grief|taught/assisted to identify coping skills to manage interpersonal problems|encouraged physical activity|encouraged and emphasized hygiene standards|normalized feelings of sadness and responses|explored potential reasons for sadness/pain |assisted youth to connect anger/guilt with depression/depressive thought patterns"]

Stressors disclosed: [checkbox value="|money|school|self-esteem|education|housing|future employment|mood|family|school work|grief and loss|illness|transitions|legal difficulties|peer group|peer relationships"]

Youth Strengths: [checkbox name="strengthz" value="Loves learning new things and will seek out knowledge|Has good reading comprehension|Likes to find out about historical events around the world|tolerant of others who have cultural, ethnic, or racial differences|youth expresses love and empathy towards family|youth expresses love and empathy towards family| able to pay close attention to details|good organizational skills|good personal hygiene|good at sharing with others|friendly to others|able to work out their own conflicts with others|polite and has good manners|Has at least one good friend|Enjoys socializing with others|can express how they are feeling|optimistic attitude|is able to effectively use non-verbal cues to communicate with others|Handles verbal feedback well|Explains ideas or concepts well to others|Is able to plan for the future and describe future goals|Possesses a sense of personal responsibility|Understands sarcasm, enjoys telling jokes|Can care for the family pet|Likes to exercise will initiate independently|will accept unsolicited adult assistance/help without resistance|Can adapt to changes in daily schedule with proper warning and notification and explanation|Thinks out-of-the-box to find unconventional and creative solutions|Has a good sense of time, can plan|Is curious about the world around him/her|willingness to forgive and give people second chances|outstanding memory in areas of interest|Youth has skills to manage triggers|Youth is able to achieve personal goals and needs|Youth possesses stress management skills|Youth is able to identify feelings and express them accurately|Youth has strong problem-solving and coping skills|Youth's friends and peers are a positive influence|Youth has a strong, stable support system|Youth acknowledges the existence and extent of issue(s)|Youth is aware of the impact of issues(s)|Youth has sufficient knowledge/understanding of issue(s)|Youth accepts responsibility for addressing issue|Youth understands how issues can negatively affect emotions||Youth has negative or distorted beliefs regarding issues|Youth understands the impact of issues on other areas of life|Youth is willing and motivated to participate in treatment"].

Family strengths and resources: [checkbox name="strengthsnresources" value="family resides in a safe home, free of violence or extreme danger|family has reliable transportation|family has a strong support system in the community|family has access to and utilizes public assistance|children, and adults are treated as equals by one another|children are given choices and not subjected to authoritarian discipline| literacy is valued and supported outside of school|family maintains a clean and hygienic home free of hazards and health risks|praise and positive reinforcement are favored by parents|parent(s) are in good mental and physical health|family participates in activities of cultural or religious significance|parents maintain reliable and fair rules and expectations for children/youth|family maintains regular routines and schedules for school, work, play, meals, etc|positive and affectionate touch and words are exchanged regularly for both adults and children|family has extended social resources such as grandparents, church members, family friends etc to rely on||||"].

Engagement: [checkbox name="engagement" value="no concerns, engaged well|avoided eye contact|fixed staring|glared at author|dependent and needy|dramatic and theatrical|passive and difficult to engage|inaccessible|asserted 'I don't know' to most questions|didn't seem interested in treatment|seemed unmotivated to change|was silly and joking around|was acting out|deffered to parent throughout session|critical and verbally combative|sarcastic and taunting|irritable|fatuous|flirtatious|demanding|threatening|suspicious and guarded|defensive and resistant|argumentative"]
The youth is currently displaying [select value="symptoms of|well managed|moderately managed|poorly managed"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|substance use disorder|cognitive impairment|impulsivity|mood lability|ADHD|ODD|autism spectrum disorder"][textarea memo="other" default="" rows="1"] which is [select value="potentially linked to|related to|likely caused by|likely exacerbated by|likely the result of"] [checkbox value="their substance use disorder|their trauma history|their depressive disorder|their anxiety disorder|their bipolar disorder|interpersonal/family conflict|family/social stressors|maladaptive behaviors|poor psychosocial support systems|engagement in sessions|improvements in social funcitoning|enagement in personal care|participation in after school activities"][textarea memo="other" default="" rows="1"]. The youth may benefit from [checkbox value="continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention|continuation of current psychotherapy|engaging in grief therapy|engaging in CBT|engaging in family therapy|enhanced psychosocial supports|increasing personal time and self-care"][textarea memo="other" rows="1"].


MHP impressions of family functioning impacting on the youth: [checkbox value=" nothing of note|struggle to problem-solve together|children have too much control|parentification of the children noted|ineffective communication|unaware of their emotional needs|the parents seem emotionally unresponsive|high expressed emotion|parents struggle to set limits|struggles for control|low warmth|parental conflict|parents are prioritizing their needs|general functioning is poor|a lack of assigned roles|splitting behaviors noted|parents are time poor|parents misuse substances|strict rules are impairing youth's development|parents struggle with finances|family is too big for parents to manage effectively"]


Barriers: [text name="variable_3" default=""][checkbox value="nothing of note|is not very motivated to change|lacks a strong education background|experiences significant work stress|has housing problems|has an over-burdening debt|experiences economic disadvantage|is not very psychologically minded|engaging in fights at school|has very poor insight|lives in a challenging social environment|has financial stress|over-identifies with sick role|has ongoing legal problems|has background of childhood adversity|has history of victimization|is unemployed|continues to expect situations will be harmful/dangerous due to trauma|has chronic medical problems|is pregnant|has contempt of therapy in general|has discord with family|has discord with most people|has extreme beliefs|has personality instability|has significant lifecycle transition difficulties|has substance misuse concerns|has low self-efficacy|has not formed enough trust for rapport|has medication adherence and compliance problems|parent has rigid beliefs and expectations|has relationship problems|has feelings of hopelessness|is unaware of problem|is denying of the problem|low distress tolerance|is too withdrawn to build rapport|has no motivation to change"].
Next session address: [text name="variable_20" default=""][checkbox value="learn relaxation skills|learn meta-cognitive detachment|developing greater insight| repair sibling conflict|enhance distress tolerance skills|feeling more hopeful about the future|improving sleep|enhancing a sense of self-efficacy|identifying support system|reducing physical pain|increasing mental health knowledge|becoming more assertive|enhancing problem-solving skills|increasing resilience factors|modifying distorted cognitions and beliefs|becoming motivated to treat medical concerns|improving medication adherence and compliance|feeling enhanced self-agency|strengthening-ego functioning|encourage boundary setting|Improve insight|Enhance agency|Consolidate identity|Enhance self-esteem|Recognizing and handling feelings|Improve reality-testing|Improve family relationships|Improve school relationships|Encourage play with peers|improve social awareness|improve assertiveness|reduce envy felt towards others|encourage self-acceptance|practice problem-solving strategies|build trust in adults|encourage enjoyment and fun"].
Upcoming session scheduled for [date name="variable_1" default="05/20/2022"]
MHP for .



MHP:

Stressors disclosed:

Youth Strengths: .

Family strengths and resources: .

Engagement:
The youth is currently displaying other which is other. The youth may benefit from other.


MHP impressions of family functioning impacting on the youth:


Barriers: .
Next session address: .
Upcoming session scheduled for

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