DAP Note Psychotherapy
D Session focus: [checkbox name="focus" value="History/Background|Stressors/Coping strategies|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"] 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 The Client reported [checkbox value="increased|decreased|no significant change in|variable"] symptoms of [checkbox value="anxiety|depression|poor impluse 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. Overall Progress: [checkbox name="progress" value="None|Regression|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|Work/School|Intimate Relationships|XXX"] [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 Client Homework [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."] 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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