Shorter Note JD

[text name="first_name" default=""][comment memo="First Name"]
Start Time: [text name="Start" default="" ]--End Time: [text name="End" default=""]
Duration: [calc value="score1=((End)-(Start))-40"] minutes
[checkbox name="code_guide" value="" memo="show code guide"][conditional field="code_guide" condition="(code_guide).is('')"][comment memo="90837: * (53-89 minutes)"]
[comment memo="90834: (38-52 minutes)"]
[comment memo="90832: (16-37 minutes)"]
[comment memo="90791: Intake/Assessment"]
[comment memo="90847: Family/conjoint w/ patient present (50 minutes)"]
[comment memo="90846: Family w/o patient present (50 minutes)"]
[comment memo="90853: Group Therapy"]
[comment memo="90839: * Crisis (up to 90 minutes)"]
[comment memo="90840: + Crisis (each add'l 30 min block beyond initial 74 min)"]
[comment memo="90785: + Interactive Complexity due to maladaptive communication, use of interpreter, caregiver emotions or behavior interfere with visit, mandated report to 3rd party, required contact with school or probation/parole (use with 90791, 90832, 90834, 90837, or 90853)"][/conditional]
Billing Code: [select name="billingcode" value="90837 *|90834|90832|90791|90846|90847|90853|90839 *"]
[checkbox name="add_ons" value="" memo="show add-on codes"][checkbox name="Extended" value="" memo="* extended session length"][conditional field="add_ons" condition="(add_ons).is('')"][checkbox name="90840" value="90840 " memo="+ Crisis (each add'l 30 min block beyond initial 74 min)"][checkbox name="90840" value="90840 " memo="+ Crisis (each add'l 30 min block beyond initial 74 min)"][checkbox name="90785" value="90785" memo="+ Interactive Complexity due to maladaptive communication, use of interpreter, caregiver emotions or behavior interfere with visit, mandated report to 3rd party, required contact with school or probation/parole (use with 90791, 90832, 90834, 90837, or 90853)"][/conditional]
[conditional field="Extended" condition="(Extended).is('')"]* Medical necessity/factors influencing length and/or frequency of sessions include: [checkbox name="extended_reasons" value="necessary for the therapeutic intervention utilized in session|rapport building with client|to address new symptoms or re-emergence of old symptoms|assessment and stabilization|significant trauma history necessitates additional time for disclosure and containment|to address complicated issues related to diagnoses and clinical presentation|grounding needed for symptoms that emerged during session|reviewed homework|client requested longer session due to decreased frequency of sessions|to prevent escalation to more intensive level of care|client crisis/acute issue|utilizing exposure therapy for ptsd, panic disorder, OCD or specific phobia|an unexpected complication resulting from pharmacotherapy|parental involvement for psychoeducation or anger management skills|BPD diagnosis requiring DBT sessions|for rapport building with new client|the client requesting additional session time and or increased frequency|a history of trauma|time necessary to address and contain intense emotional content|preventative measures to avoid higher level of care|necessary for the therapeutic intervention utilized in session|addressing new or re-emerging symptoms|limited health support network|client is unable to share content with others in support system due to nature of topic|EMDR Protocol being utilized|bi-weekly sessions|monthly sessions to maintain acquired skills|symptoms are impacting multiple domains of life (Relationships, work, school community)|IFS Protocol being utilized"]. [text][/conditional]
[var name="first_name"] arrived [select name="on_time" value="on time|5-10 minutes late| more than 10 minutes late|xxxxxx"] for [select name="scheduled_crisis" value="scheduled follow up|urgent crisis|xxxxxx"] [select name="mode" value="face to face|telehealth|xxxxxx"] session. [text name="variable_1" default=""][comment memo="addt'l attendees; client location if telehealth"]. [select name="Presentation" value="Client presented as calm and cooperative, with casual dress, normal grooming and hygiene. No apparent abnormalities of thought, affect, or behavior and no unusual movements or psychomotor changes.|ABNORMAL xxxxxx Client presented as NOT calm or uncooperative, with bizarre dress, poor grooming or hygiene. Remarkable abnormalities of thought, affect, or behavior are present. Remarkable or unusual movements and psychomotor changes.|xxxxxx"][text name="variable_1" default=""]
Affect: [select name="Affect" value="normal range, reactive and mood congruent.|Generally positive, reactive and mood congruent.|Calm and reflective, reactive and mood congruent.|Distressed or labile.|Detached, blunted, flat, shallow, or tired.|Inappropriate to context.|xxxxxx"][text name="variable_1" default=" "]
Mood: [select name="Mood_default" value="Euthymic, reactive and congruent with content.|"] [select name="Mood_1" value="|Mildly|Moderately|Quite"] [select name="Mood_2" value="|anxious|depressed|dysphoric|elevated|angry|irritable|hostile"][text name="variable_1" default=". "][select name="Mood_3" value="|Mood is congruent with content.|Mood is incongruent with content."][text name="variable_1" default=" "]
Thought processes and content are [select name="Thought_Process" value="goal directed and logical|disorganized|xxxxxx"]. [text name="variable_1" default=" "]
Risk Assessment: [select name="Risk" value="No evidence or report of suicidal or homicidal ideation.|Client denies suicidal or homicidal ideation.|Client denies concerns about safety across settings.|Safety concerns reported|."][text name="variable_1" default=" "][checkbox name="expand_safety" value="" memo="expand safety"][conditional field="expand_safety" condition="(expand_safety).is('')"][checkbox name="Safety" value="Client denied suicidal ideation|Client reported passive suicidal ideation|Client reported active suicidal ideation|Client reported passive homicidal ideation|Client reported active homicidal ideation|has a plan|has intent to follow through with plan|has means to follow through with plan|higher level of care is needed|urgent assessment for higher level of care is needed|client participated in safety planning|support person participated in risk reduction and safety planning|client unwilling/unable to participate in safety planning|LPC to complete mandated report to appropriate agency|client disclosed current safety concerns"].[text name="variable_1" default=" "][/conditional] .
[text name="variable_1" default="Client reports"][comment memo="quote from patient about how things are going"]
Current concerns include: [checkbox name="variable_1" value="depression|anxiety|panic|ADHD|PTSD|OCD|bipolar disorder|insomnia|psychosis|alcohol/drug use|personality disorder|neurocognitive concerns|recent life changes|recent significant loss|recent trauma|difficulty managing emotional reactions|interpersonal conflict|family conflict"].
[text][checkbox name="depression" memo="depression" value=""][checkbox name="anxiety" memo="anxiety" value=""][checkbox name="panic" memo="panic" value=""][checkbox name="ADHD" memo="ADHD" value=""][checkbox name="PTSD" memo="PTSD" value=""][checkbox name="OCD" memo="OCD" value=""][checkbox name="bipolar" memo="bipolar disorder" value=""][checkbox name="insomnia" memo="insomnia" value=""][checkbox name="psychosis" memo="psychosis" value=""][checkbox name="alcohol" memo="alcohol" value=""][checkbox name="opioid" memo="opioid" value=""][checkbox name="person" memo="personality_relational" value=""][checkbox name="neuro" memo="neurocognitive" value=""]
[conditional field="depression" condition="(depression).is('')"]
Depression is reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client is reporting [checkbox value="no concerning progression of symptoms|little interest or pleasure in doing things|hopelessness|helplessness|sleeping too much|difficulty getting to sleep|difficulty staying asleep|feeling tired or having little energy|poor appetite|overeating|feelings of inadequacy|irritability|poor concentration|psychomotor retardation|psychomotor agitation|suicidal ideation"]. [textarea memo="Additional information" rows="1"][/conditional]
[conditional field="anxiety" condition="(anxiety).is('')"]
Anxiety is reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client is reporting [checkbox value="no concerning progression of symptoms|feeling restless/wound up|fatigue|difficulty concentrating|irritability|difficulty falling to sleep|difficulty staying asleep|feeling tired or having little energy|muscle tension|headaches|feeling overwhelmed|irritability|poor concentration|restlessness|loss of appetite"]. [textarea memo="Additional information" rows="1"][/conditional]
[conditional field="panic" condition="(panic).is('')"]
Panic symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client is reporting [checkbox value="no concerning progression of symptoms|palpitations/racing heart|sweating|shaking|shortness of breath|chest pain/tightness|nausea/stomach cramps|numbness/tingling|fear of losing control|closed in feeling|feeling overwhelmed|heat sensations|chills|trembling/shaking"]. [textarea memo="Additional information" rows="1"][/conditional]
[conditional field="ADHD" condition="(ADHD).is('')"]
ADHD symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|inattention|careless mistakes|difficulty sustaining attention|problems following conversations|easily side tracked|difficulty organizing tasks/activities|avoidance and procrastination|forgetfulness|easily distracted by unrelated thoughts|fidgeting|inability to relax|excessive talking|difficulty waiting/reduced patience"]. [textarea memo="Additional information" rows="1"][/conditional]
[conditional field="PTSD" condition="(PTSD).is('')"]
PTSD symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client is reporting [checkbox value="no concerning progression of symptoms|nightmares|flashbacks|intrusive memories/thoughts|avoidance|negative affect|loss of interest|isolation|difficulty experiencing positive emotions|irritability|annoyance|risky/self destructive behaviors|hypervigilance|heightened startle reaction|difficulty concentrating|difficulty falling asleep|difficulty staying asleep"]. [textarea memo="Additional information" rows="1"][/conditional]
[conditional field="OCD" condition="(OCD).is('')"]
OCD symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client is reporting [checkbox value="no concerning progression of symptoms|recurring thoughts|recurring images|recurring urges|urge to neutralize thoughts|repetitive behaviors|counting|focusing on geometry|checking|isolation|organizing/aligning objects|hoarding|fear of germs/illness|blinking|touching/tapping|needing constant reassurance|fear of dread|mental rituals|excessive time spent thinking or engaging in compulsive behavior"]. [textarea memo="Additional information" rows="1"][/conditional]
[conditional field="bipolar" condition="(bipolar).is('')"]
Bipolar symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client is reporting [checkbox value="no concerning progression of symptoms|elevated mood|irritable mood|increased self esteem|loss of sleep|racing thoughts|difficulty keeping up with thoughts|increased desire to speak|feeling more distracted|feeling more energetic|increased desire to engage in activities|agitation|impulsive behaviors|feeling more social/outgoing|increased sex drive|spending money|using drugs/alcohol"]. [textarea memo="Additional information" rows="1"][/conditional]
[conditional field="insomnia" condition="(insomnia).is('')"]
Insomnia symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client is reporting [checkbox value="no concerning progression of symptoms|difficulty falling asleep|difficulty staying asleep|early morning awakening|nightmares|vivid dreams|thrashing in sleep|sleep walking|daytime sedation/fatigue|sleep talking|night terrors|confusion|sleep related eating|hallucinations going to sleep|hallucinations when taking up"]. [textarea memo="Additional information" rows="1"][/conditional]
[conditional field="psychosis" condition="(psychosis).is('')"]
Psychotic symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client is reporting [checkbox value="no concerning progression of symptoms|delusions of persecution|jealous delusions|somatic delusions|grandiose delusions|religious delusions|thought broadcasting|thought insertion|auditory hallucinations|visual hallucinations|disorganized thoughts|disorganized behaviors|confusion|social isolation|loss of motivation|problems focusing|suicidal thoughts|anxiety"]. [textarea memo="Additional information" rows="1"][/conditional]
[conditional field="neuro" condition="(neuro).is('')"]
Cognitive symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client is reporting [checkbox value="no concerning progression of symptoms|difficulty with complex attention|poor executive functioning|difficulty with short term memory|difficulty with long term memory|motor difficulties|confusion|repetitive behaviors|misplacing objects|difficulty understanding context|difficulty formulating speech|forgetting names/words|loss of interest|confusion|social isolation|loss of motivation|paranoia|visual hallucinations|auditory hallucinations|obsessive behaviors|hoarding behaviors|tremors|night terrors|sleeping during the day|not sleeping at night|agitation|threatening behaviors|inappropriate behaviors"]. [textarea memo="Additional information" rows="1"][/conditional]
[conditional field="alcohol" condition="(alcohol).is('')"]
Alcohol use symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client is reporting [checkbox value="no concerning progression of alcohol use|daily drinking|drinking more than anticipated|inability to cut down on drinking|cravings to drink|blackouts|hangovers|urges to drink|missing work due to drinking|drinking alone|drinking and driving|drinking to fall asleep|escalating alcohol use|tremors|nausea|vomiting|headaches|sweating|anxiety|racing heart|confusion|visual hallucinations|auditory hallucinations|seizures"]. [textarea memo="Additional information" rows="1"][/conditional]
[conditional field="opioid" condition="(opioid).is('')"]
Opioid use symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client is reporting [checkbox value="no concerning progression of symptoms of opioid use|cravings|urges to use opioids|continued opioid use|use of fentanyl|recent overdose|drowsiness|dizziness|fainting|fatigue|chest pain|difficulty breathing|missing work|irritability|pinpoint pupils|nausea|vomiting|loss of appetite|constipation|diarrhea|stomach cramping|weight loss|racing heart|sweating|chills|palpitations|tearing eyes|yawning|insomnia|bone pain|goose bumps|tremors|leg swelling|yellowing of eyes|loss of libido|confusion|visual hallucinations|auditory hallucinations"]. [textarea memo="Additional information" rows="1"][/conditional]
[conditional field="person" condition="(person).is('')"]
Relational and personality related symptoms are [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"].
Client is reporting [checkbox value="no concerning progression related to interpersonal relationships, impulsivity, behavioral regulation, or affect regulation|unstable relationships with others|idealizing and devaluing|identity disturbance|feelings of emptiness|affective lability|excessive anger|aggression|efforts to avoid abandonment|impulsive behaviors|suicidality|self injurious behavior|thrill seeking|paranoia|dissociation|attention seeking"]. [textarea memo="Additional information" rows="1"][/conditional]
Medication, Medical, or Legal Changes/Concerns: [textarea name="Med_Changes" default=" None reported."]
Functional Status
Relational: [select name="Rel" value="intact|variably impaired|impaired"]
[text name="variable_1" default=""]
Occupational/School: [select name="Occ_Edu" value="intact|variably impaired|impaired"]
[text name="variable_1" default=""]
Physical: [select name="Phy" value="intact|variably impaired|impaired"]
[text name="variable_1" default=""]
Session Goals: [checkbox name="Goals" value="symptom reduction|skill acquisition|improve functioning|improve health|maintain positive gains|reduce ineffective behaviors|safety planning|treatment review|termination/discharge"]
The main themes of the session were: [checkbox name="Theme_Specific" value="dealing with panic and anxiety states|exploration and coping with depression and sadness|awareness and exploration of feelings of powerlessness, hopelessness and helplessness|exploration of capacity to return to work/school|coping with and management of impulses to self-mutilate|coping with and management of impulses to self-harm|coping with suicidal thoughts and feelings|coping with exhaustion and burn out in work activities|working through and management of anorectic behavior and related difficulties|coping and working through of difficulties with disordered eating|coping with and working through of drug dependence and abuse|coping with and working through of addictions and related concerns|exploration of sleep disturbance|coping with sexual difficulties|awareness and exploration of possible psychosomatic reactions|awareness and exploration of perfectionistic tendencies|issues of impulse control and containment of affects|awareness and exploration of underlying aggression and feelings of rage|exploration and working through of guilt and related anxieties|exploration of anxieties regarding healthy dependency|awareness and exploration of underlying needs for care and support|awareness and exploration of tendency to push others away in response to anxiety|exploration and working through of difficulties with trust in interpersonal relationships|development of self-care and self-function|development and working toward greater creativity and capacity for play|development of expanded spiritual and creative experience|development of occupational functioning and pleasure in work activities|xxxxxx"]
[comment memo="Conditional Themes List"][checkbox name="Relational" value="" memo="Relational Themes"][checkbox name="Trauma" value="" memo="Trauma Themes"][checkbox name="Identity" value="" memo="Identity Themes"][checkbox name="Process" value="" memo="Process Themes"][checkbox name="Grief" value="" memo="Grief/Mourning/Loss Themes"][checkbox name="Adjustment" value="" memo="Adjustment Themes"][checkbox name="DailyLife" value="" memo="Daily Life Themes"]
[conditional field="Relational" condition="(Relational).is('')"][checkbox name="Theme_Relational" value="relational difficulties|recent relational conflict|coping with relational frustrations|struggles with social anxiety|coping with anger and envy in interpersonal relationships|coping with feelings of rejection in interpersonal relationships|difficulties with boundaries in interpersonal relationships|securing appropriate boundaries|crisis situation in family|conflict with family members|working through interpersonal/family experiences|interpersonal difficulties with spouse/partner|sexual difficulties and/or concerns|exploration of family life|exploration of relationship with father|exploration of relationship with mother|exploration of relationships with sibling(s)|exploration of relationships with children|exploration of parenting concerns|exploration of relationships with friends|exploring relational concerns and issues in the workplace|coping with conflict with authorities at work|exploring relational concerns and issues in school|exploration of positive interpersonal experiences|recent positive relational experiences|reparation of broken and/or strained interpersonal relationships|exploration of recent conflict with friend(s)|exploring forgiveness and reparation in interpersonal relationships|addressing issues related to trust in interpersonal relationships|xxxxxx"][/conditional][conditional field="Trauma" condition="(Trauma).is('')"][checkbox name="Theme_Trauma" value="expression of stressful experiences|exploration and discussion of recent traumatic experiences|exploration of childhood traumas and neglect|exploration of multiple traumatic events and cumulative trauma in childhood/adolescence|exploration of impact of sexual abuse experiences experienced in childhood/adolescence|exploration of emotional neglect experienced during childhood/adolescence|exploration of transgenerational traumas|exploration of vicarious traumatic experiences|exploration of health concerns and illness|exploration of end of life anxieties, fears, and concerns|expression and exploration of experiences of victimization|exploring and addressing traumatic loss|exploration of the traumatic experience of the pandemic|coping with the traumatic nature of the pandemic|exploration of traumatic isolation and disconnection from others|exploration of experienced cumulative trauma|exploration of racial stress and racial trauma|exploration of traumatic experiences of discrimination|exploration of sexual assault experience(s)|coping with and managing recent sexual assault experience|expression and exploration of recent traumatic injury|exploration and discussion of collective/cultural traumatic experiences|coping with experienced assault and/or physical threat or violence|exploration of traumatic experiences endured during military service|addressing and exploring post-traumatic reactions and experiences|exploration and coping with a recent serious medical diagnosis|exploration and discussion of traumatic experiences impacting the couple|exploration and discussion of traumatic experiences impacting the family|******"][/conditional][conditional field="Identity" condition="(Identity).is('')"][checkbox name="Theme_Identity" value="exploration of low self-esteem and poor confidence|working towards improved self-esteem and confidence|exploration of bodily anxieties and distorted body image|conflicts and concerns regarding ethnic/cultural identity|exploration of anxieties regarding gender and/or sexuality identity|exploration of conflicts regarding masculinity and/or issues of male sexuality|exploration of conflicts regarding femininity and/or issues of female sexuality|exploration of conflicts and anxieties regarding masculinity|exploration of conflicts and anxieties regarding femininity|exploration of obstacles to identity development in adolescence|exploration of adolescent identity concerns|expression and exploration of crisis of identity|working towards integration of adult identity|exploration of mid-life identity concerns and meaning|exploration of late-life identity formation and concerns|life-review as part of later-life identity consolidation; expression and exploration of discontinuities in self-state experiences|difficulties with boundaries and self-assertion|awareness and exploration of deficits in self-preservation|exploration of feelings of lack of entitlement|working towards securing a 'right to a life,' appropriate entitlement and independence; exploration and working through of 'false-self' states and their relationship to early life experiences; exploration of guilt feelings and inhibitions regarding pleasure and success|exploration of distress related to body-dysmorphic perceptions|exploration of distress and/or concerns related to transgender identity|exploration of distress and/or concerns related to disclosure of sexual identity|exploration of uncertainties surrounding gender and/or sexuality|exploration of experienced racial/cultural identity|exploration and development of professional/work-life identity|communication and discussion regarding issues of sexuality and/or gender identity within the family|******"][/conditional][conditional field="Process" condition="(Process).is('')"][checkbox name="Theme_Process" value="exploration of life experiences and self-understanding|expression and development of 'true self' experiences and enhanced authenticity|development of self-care and self-preservation|development of inner security|ongoing work toward greater self-empathy|ongoing work towards greater mindfulness|exploration and working through of inner self-criticism|self-punishment and self-denial|working through and exploration of inhibitions regarding success and accomplishment|exploration of conflicts regarding entitlement and self-validation|exploration of dream life|exploration of fantasy life|exploration of the therapeutic relationship|ongoing working through of transferences|exploration of characterological and interpersonal difficulties as revisited within the therapeutic relationship|continued exploration of the impact of early life on current identity|expression and discussion of problematic beliefs and schemas|exploration and evaluation of target behaviors and areas of concern|discussion of medication and its impact|exploration and discussion of recent homework assignments|review of the therapeutic work to date|exploration of therapeutic goals and aims|revision of therapeutic goals and aims|recent progress being made in the therapy|obstacles experienced in the therapy|the impact of teletherapy on the therapy experience|******"][/conditional][conditional field="Grief" condition="(Grief).is('')"][checkbox name="Theme_Grief" value="expression and exploration of recent loss|continued working through of traumatic losses|continued mourning of childhood losses|exploration of unhappy childhood experiences and losses throughout life|expression and exploration of prior losses and grief|******"][/conditional][conditional field="Adjustment" condition="(Adjustment).is('')"][checkbox name="Theme_Adjustment" value="transition to adulthood and adult responsibilities|strain of mid-life transitions|coping with recent changes in family life|late-life adjustment and coping with age-related changes|adjustment to recent motherhood|adjustment to recent fatherhood|parenting anxieties and concerns|adjustment to separation from child/children|work life and occupational concerns|coping with stress at school|adjustment to university life and studies|adjustment to new demands in life situation|adaptation to physical illness|adaptation to physical illness|******"][/conditional][conditional field="DailyLife" condition="(DailyLife).is('')"] [checkbox name="Theme_Daily" value="management and coping with daily life|structuring of daily life and making plans for the future|coping with day to day organizational difficulties|dealing with self-care (e.g., eating, sleeping, finances)|dealing with inhibitions regarding help seeking and turning to others for support|working towards the further development of hobbies and constructive leisure activities; working toward improved health life style|how to create better balance between work, relational, recreational, and self needs|development of greater self-assertion and effective interpersonal communication|development of hobbies and leisure activities|identifying obstacles to mental and emotional wellbeing|******"][/conditional]
Clinical Interventions: [checkbox name="Interventions" value="Therapist provided supportive validation and reflective listening, along with aiding client in processing thoughts, emotions and perceptions related to issues at hand and worked to develop more effective solutions/coping.|Therapist utilized circular questioning, reflecting feelings and metacommunication to support client in expressing and exploring their feelings.|Therapist used metacommunication, circular questioning and gentle challenging to help client examine patterns in interpersonal relationships and to promote introspection regarding their emotions, thoughts and behaviors.|Therapist utilized reflection and validation of feelings, encouragement and metacommunication throughout the session to help client gain insight.|The therapist and client participated in therapy activities to facilitate problem solving and interpersonal social skill development including expression of emotions and responses to emotions, as well as the examination of the relational patterns.|The therapist assisted client in progressing toward goals throughout the session by assessing current coping skills and encouraging expression of feelings and adaptation of coping skills, as well as exploring the development of additional ones. The therapist provided activities to strengthen the sensory response systems and self-regulation of the client through employing various therapy modalities and therapy techniques as appropriate.|Therapist used solution focused techniques to help client identify solutions that are effective to improve functioning and overall wellbeing.|Therapist assisted client identifying cognitive distortions and used cognitive restructuring techniques to re-frame challenges and difficult feelings to positive outlooks for self.|Therapist and client explored their stressors and frustrations. Therapist validated frustrations and empathized with the experience. Therapist and client explored ways to improve distress/frustration tolerance, including healthy distraction (with pleasurable activities, focusing on others, counting, and tasks/chores), radical acceptance, self-soothing techniques, mindfulness, coping thoughts, and self-affirming thoughts.|Therapist and client practiced assertive communication skills to increase interpersonal effectiveness.|Therapist used MI open/closed ended questions and reflective listening.| Therapist provided psychoeducation.|Therapist and client collaborated on ....|Therapist utilized person-centered counseling skills in order to build the therapeutic relationship. Therapist utilized active listening skills in order to gather information, promote insight and autonomy, convey empathy and understanding, and validate the client's experience.|Therapist and client reviewed creation of treatment plan; client identified areas of concern and goals they would like to work on through therapy|Therapist maintained focus on providing a supportive and responsive relationship with client to foster their ability to cooperate.|XXXXXX||"]
[text name="variable_1" default=" "][checkbox name="more_interventions" value="" memo="expand more interventions"]
[conditional field="more_interventions" condition="(more_interventions).is('')"] Additional interventions and strategies included: [checkbox name="More_Interventions" value="attuned listening|cognitive/behavioral techniques|emphasis on self-expression|normalization|psycho-education regarding symptom-management and skill building|play therapy|interpretation|parent education|DBT-informed|IFS protocol|validation|rapport building|emotional expression|relaxation techniques|supportive therapy|increase coping|identify/reframe thinking|problem-solving|positive reinforcement|communication skills|identify triggers|clarification|behavioral rehearsal|assertiveness training|art therapy|child behavioral strategies|reframing|active listening|setting appropriate boundaries|Tx plan review|strengthen support systems|family Hx/dynamics|trauma-informed interventions|role play|modeling|child-centered play therapy techniques|TF-CBT|cognitive restructuring|family therapy|expressive arts|focus on improved problem solving and coping|expressive art techniques|supportive techniques|emphasis on here-and-now functioning|evaluation and exploration of problematic automatic thoughts|targeting more effective problem solving and coping skills in daily life|addressing problematic core beliefs|evaluating and addressing dysfunctional thoughts|emphasis on self-monitoring of thoughts, emotions and behavior|techniques for the development of greater confidence and self-efficacy|self-assertiveness and confidence building|a focus on anger management and containment of acting out|exploration of appropriate interaction and communication|focus on social skills enhancement and practice|guided imagery used to improve mindfulness and improve impulse-control|review informed consent/confidentiality|clinical diagnostic assessment/clarification"]. [text name="variable_1" default=" "][/conditional]
[select name="variable_1" value="Addressing these psychological components should increase the response rate or at least mitigate symptoms, decreasing the risk for decompensation of underlying illness or the need for additional interventions or medications.|"][text name="variable_1" default=" "]
Progress/Effectiveness and response to intervention: [select name="RTI" value="Some progress apparent. Client was actively engaged throughout the session and responded well to the intervention offered. Treatment continues to show good evolution and development|Fluctuating/intermittent progress apparent. Although the current crisis has overwhelmed the client's resources, they were engaged and communicative throughout the session.|Client is disengaged from the therapuetic process and progress is minimal.|Client is maintaining past gains/stable. Current focus on maintenence and relapse prevention. We are moving toward termination via reduced session frequency."][text name="variable_1" default=" "][checkbox name="more_RTI" value="" memo="expand more progress and RTI options"]
[conditional field="more_RTI" condition="(more_RTI).is('')"][checkbox name="Progress" value="some progress apparent|a significant reduction in symptoms continues|client actively participated in the counseling process|client participated actively in development of client-centered treatment plan|client was active and communicative throughout the session|client responded well to the intervention offered|treatment continues to show good evolution and development|client is engaged in the therapeutic process|client is disengaged from the therapuetic process|significant improvement|maintaining past gains/stable|near completion of treatment|current focus on maintenance/relapse prevention|some increase in symptoms|significant increase in symptoms|progress with self-understanding and self-insight|there is continued development of the clients capacity for self-care and life management|developments continue in the areas of family and relational functioning|developments continue in the areas of occupational functioning and achievement|developments continue in the areas of healthy separation and interdependence|developments continue in the area of containment of harmful acting out behavior|the client continues to make steady gains in self-esteem and confidence|current crisis has overwhelmed client’s resources|regressed|no notable change|slight progress|fluctuating/intermittent progress"].[text][/conditional][text name="variable_1" default=" "][comment memo="quote from patient about how the session went"]
Ongoing Plan: [select name="plan" value="Treatment to continue as indicated, client to practice strategies discussed in session.|Increase session frequency due to increased symptoms or safety concerns|Moving toward discharge, decrease session frequency and monitor for stability and maintenence of gains|Discharge and close file| xxxxxx|Higher level of care needed, referred to xxxxxx for assessment and indicated treatment before returning to outpatient treatment"][text name="variable_1" default=" "][checkbox name="more_plan" value="" memo="expand ongoing plan options"]
[conditional field="more_plan" condition="(more_plan).is('')"][checkbox name="Plan" value="treatment to continue as indicated|increase/decrease session frequency|move toward discharge|discharge|referral to xxxxxx|higher level of care needed|follow up|homework xxxxxx|practice xxxxxx|follow up appointment scheduled|client/guardian will call to schedule follow up appointment|plan for next session: xxxxxx"][text name="variable_1" default=" "][/conditional][select name="next" value="Next session |Treatment on hold.|File closed.|"][select name="scheduling" value="|is scheduled for 1 week out.|is scheduled for 2 weeks out.|is scheduled for 3 weeks out.|is scheduled for 1 month out.|is scheduled for xxxxxx.|to be scheduled by client/guardian.|to be scheduled after assessment for higher level of care and completion of recommended treatment.|xxxxxx"][text name="variable_1" default=" "]
First Name
Start Time: --End Time:
Duration: score1=((End)-(Start))-40 minutes
show code guide
Billing Code:
show add-on codes * extended session length

first_name arrived for session. addt'l attendees; client location if telehealth.
Thought processes and content are .
Risk Assessment: expand safety .
quote from patient about how things are going
Current concerns include: .
depression anxiety panic ADHD PTSD OCD bipolar disorder insomnia psychosis alcohol opioid personality_relational neurocognitive

Medication, Medical, or Legal Changes/Concerns:

Functional Status



Session Goals:

The main themes of the session were:
Conditional Themes List Relational Themes Trauma Themes Identity Themes Process Themes Grief/Mourning/Loss Themes Adjustment Themes Daily Life Themes

Clinical Interventions:
expand more interventions

Progress/Effectiveness and response to intervention: expand more progress and RTI options
quote from patient about how the session went

Ongoing Plan: expand ongoing plan options

Result - Copy and paste this output:

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