DAP in-home adolescent 2.0
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|grandparents and youth|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 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|(telehealth/office location)| in a community and also a home setting"]. 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 stressors|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 the 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 behavior|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 and exploration|clarified expectations|reinforced use of positive self-talk|assisted to identify and explore triggers related to diagnosis|gave psychoeducation on relevant diagnosis|Facilitated/explored understanding of risk factors|discussed 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 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|explored potential reasons for sadness|assisted the 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 reports feeling loved by 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 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 verbally identify feelings |Youth has strong problem-solving 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 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 health| family is in good 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|positive and affectionate 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"]. Current impairments, behaviors, experiences reported to or observed by MHP: [checkbox name="symptums" value="Grief/Loss|Feelings of Guilt/Shame|Helplessness|Hopelessness|reported feeling of low self worth|reported feeling numb|Suicidal Ideation |Self-Harm|Homicidal Ideation|Aggression (Verbal)|Aggression (Physical)|Rage|Anger|Frustration|Anxiety|Panic Attacks|Increased Startle Response|Racing Thoughts|Rumination|Obsessive Thoughts reported or noted|Compulsive Behaviors/Thoughts|Nightmares|Avoidance|Depressive symptoms increase|Sad or Down Most Days of this Week|Anhedonia|difficulty with concentration/Memory|increased difficulty completing Tasks |Difficulty Following Directions|social isolation|Mood lability|manic behaviors and thoughts||Increased Sexual Activity|new sexual activity noted/stated|Increased Spending|Risky Behaviors|withdrawl from social activities|peer substance use noted|Hyperactive behaviors at school or home|Treatment avoidance|Excessive Sleeping|difficulty sleeping|Increased Appetite|Loss of appetite|Binge Eating|restrictive eating|purging|excessive dieting|Excessive Exercise|Body Dysmorphia|noticable weight loss or gain|personal hygeine decline"] 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|signs of|moderately managed|poorly managed"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|overall functional improvement|substance use disorder|cognitive impairment|chronic stress|impulsivity|mood lability|ADHD|ODD|autism spectrum disorder"][textarea memo="other" default="" rows="1"] which [select value="is potentially linked to|is related to|is likely caused by|is likely exacerbated by|is likely the result of"] [checkbox value="substance use concerns|their trauma history|their depressive disorder|their anxiety disorder|their bipolar disorder|interpersonal/family conflict|family/social stressors|reduction of stressors|parent intervention|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|more personal choice and independence|additional mental health assessment to establish correct needs/diagnosis||psychiatric consultation for medication|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"]. TREATMENT PROGRESS/PROGRESS TOWARDS TREATMENT GOALS Youth and family progress in achieving goals: [checkbox name="cb12" value="responding well to interventions|making some progress|slow/slight progress|fluctuating/intermittent progress|maintaining past gains|maintaining current goal focus|reprenting relapse|an increase in symptoms|a decrease in symptoms|a significant escalation in symptoms|minimal|improving|stable"] - as evidenced by youth and family self-report,session behavior, and clinical engagement. Suicide risk assessment at present: [checkbox name="Q58" value="Youth denies suicidal ideation and does not show any signs of immediate risk |Suicidal ideation without intention or active plan|Suicidal thoughts and realistic plans without stated intent of executing plans|Suicidal intent present along with plans and thoughts of action|lack of verbal information, MHP used clincial judgement to conclude client is in depressive state and may be at high risk of suicide or self-harm"] MHP response at time of risk assessment: MHP [checkbox name="QT" value="reminded youth of mental health resources available and encouraged open dialogue about self-harm and suicide related topics|scheduled a time to check in and reassess safety concerns on |provided phone numbers and resources for support such as the crisis hotline|requested the clients verbal confirmation of level of intent|Validated clients feelings and experiences|Created a crisis plan detailing what to do in the event of increased suicidal intent|Made verbal contract with client that the client will call the crisis line if suicidal intent becomes present or client feels they are in danger or unsure of their safety|Alerted youths parent/guardian of suicidality concerns|Supported the client in calling the crisis line for emergency support|stayed present with client to ensure safety until another form of support was utilized|Initiated emergency psychiatric care|"] [text] 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|parent struggling with time management|parents unable to meet youths needs|strict rules are impairing youth's development|low socioeconomic staus is impairing functioning|family is too big 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|engaging in fights at school|has poor insight|lives in a challenging social environment|has financial stress|over-identifies with sick role|has ongoing legal problems|has a background of childhood adversity|has a 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|initiating new social supports| feeling more hopeful about the future|improving sleep|how to address triggers|engagement decline and request youth/family feedback for improved engagement|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="08/20/2022"]
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