DAP Note Psychotherapy
D Summary:[text name="text" default=" "] Clinical Interventions used [checkbox name="Interventions" value="CBT (cognitive challenging, cognitive refocusing, cognitive reframing)|rapport building|EMDR|DBT|play/art therapy tecniques (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|mindfullness|Family Systems/Dynamics|Note: interactive commplexity- language interpretation"] A Progress towards goals and objectives: [checkbox value="progress" value="significant progress|some progress|no significant change|maintaining|regression"] Client’s response to intervention used:[checkbox name="response" value="None|Poor|Fair|Good"] Current limitations and setbacks:[checkbox name="limitations" value="conflict in interpersonal relationship with partner|peer conflict|financial stressors|trauma reminders|school stressors|life transitions|work related stressors|medication management issues|medication changes|cormorbid physical health issues|grief/loss|lack of financial resources|risk-taking behaviour|unemployment|strained familial relationships"] Current Functioning Impairments [checkbox name="impairments" value="daily tasks/responsibilities|social relationships|work|school|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"] P Between the sessions, the Client will [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.|devise a regular and adequate eating schedule, a pattern of adequate sleep and relaxation, as well as regular cardiovascular exercise."] Recommendations of Frequency: [select name="scheduling" value="weekly|bi-weekly|monthly|Next appointment to be scheduled by the guardian|The next appointment to be scheduled by the Client"]. The next appointment is scheduled for [date name="variable_1" default="today"]
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