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 client|parent|family|MHCC|social worker|grandparent(guardian)|MHCC, client guardian, client|treatment team|other MHP( )"] for [select name="dooo" value="an individual session|scheduling services|a family session| session|a discussion about case details|an initial pre-admission meeting|request_____|treatment team meeting|IEP meeting"] [select name="variable_3" value="at the client's home|at school|at a public park|"]. [checkbox name="COVID19" value="The client denied any exposure to, or symptoms of COVID-19 (fever, aches, coughing, etc) before the start of this session. "]
MHP [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 client reading on roots of social anxiety|used games and play to build rapport |explored changes in symptoms of anxiety with client|highlighted clients 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 clients 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 client 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 clients 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 client to connect anger/guilt with depression/depressive thought patterns"]
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|hauty and superior towards author"] Client 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="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"][textarea memo="other" default="" rows="1"]. Client 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 client: [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 behaviours noted|parents are time poor|parents misuse substances|strict rules are impairing client's development|parents struggle with finances|family is too big for parents to effectively manage"]
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 difficult 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|sibling conflict|increasing eating and calorie intake|decreasing ETOH misuse|enduring withdrawal of substances|enhancing 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|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 love relationships|Improve school relationships|Encourage play|improve |improve assertiveness|Reduce envy|Self-acceptance|Encourage problem-solving|Find serenity|encourage enjoyment and fun"]. Upcoming session scheduled for [date name="variable_1" default="11/10/2021"]
[checkbox name="Consent" value="This MHP reviewed the consents verbally in the pre-admission/intake meeting. The following consents were reviewed with youth and guardian: Program Participation Authorization and Release, Privacy PracticeYouth and Family Rights, Transportation, Authorization to Release Confidential and Protected Health Information (PHI) – be specific in the role but not with the name unless Parent/Guardian or youth would like specific name only, Informed Consent for In-person Services During COVID- 19 Public Health Crisis."]