Female Ind Prog Note 12.28.22

AGENDA:
[checkbox name="cb6" value="Review homework|Review assessments, screeners, and scoring|Assess mood/functioning|Assess relationship distress|Assess sexual functioning/concerns|Psychoeducation|Psychosexual education|Communication skills training|Emotion regulation skills training|Behavioral health interventions|Stress management|Pain management|Mindfulness|Safety Planning|Review of Progress|Review diagnostic conclusions/recommendations|Treatment Planning|Goal setting|Termination planning|Discuss termination|Termination "]

ASSESSSMENTS, SCREENERS, & SCORING
[checkbox name="cb7" value="Self-report and Behavioral Observation|PHQ-9|GAD-7|Compulsive Sexual Behavior Inventory (CSBI-13)|DAS|DSCS|PCS|FGSIS|Edinburg"]
UPDATE:
[textarea name="variable_1" default=""]

SESSION ISSUES/TOPICS DISCUSSED
The following tropics/concerns were discussing in session: [checkbox name="cb8" value="|-------MOOD MANAGEMENT-------|Current symptoms/functioning|Symptom management|Management of depression symptoms|Management of anxiety symptoms|Management of depression and anxiety symptoms|Emotion dysregulation|Anger issues/mismanagement|Emotional expression concerns|Distress intolerance|-------RELATIONSHIP DISTRESS------- |Relationship dissatisfaction|Conflict, argument, or regrettable incident with partner|Relationship intimacy concerns|Infidelity/affair concerns|Divorce issues|Relationship trust issues|Communication problems with partner|Relationship value conflict|-------ADJUSTMENT DISORDER-------|Adjustment to a stressor(s)|Adjustment to work changes|Adjustment to job loss|Adjustment to relationship changes|Adjustment to family life changes|Adjustment to a development event|------GRIEF LOSS-----| Death of a family member|Death of a friend|Grief reactions|Process built up regrets|Processing grief through letter writing|-------ATTACHMENT ISSUES-----|Adult attachment style issues|Attachment anxiety and avoidance|Adult attachment anxiety|Fear developing intimate relationships|Fear of interpersonal rejection and/or abandonment|Adult Attachment Avoidance|Fear of intimacy|Excessive need for self-reliance|Reluctance for self-disclosure|Negative view of others|--------ABUSE OR STALKING----- |Power and control issues|Partner psychological abuse|Berating and/or humiliation by partner|Interrogation by partner|Restriction to go freely by partner|Obstruction of assistance by partner|Threats of physical harm by partner|Threats of sexual assault by partner| Restriction of access to economic and or financial resources by partner|Isolation from friends or family by partner|Partner stalking|Stalking concerns|Made to feel and think one is crazy by partner|-------INTERPERSONAL PROBLEMS------|Interpersonal conflict(s)|Conflict with friends|Conflict with family|Conflict with coworker(s)|Poor boundary setting|Difficulty saying no to others|Passive behaviors|Aggressive behaviors|-----SEXUALUALITY FUNCTIONING-----|Sexual functioning concerns|Sexual health concerns|Sexual behavior(s) of concern|Sexual orientation/identity concerns|Sexual orientation microaggressions|Internalized homophobia|Sexual relationship dissatisfaction|Sexual communication discomfort|Sexual scripts/sexual script adjustment|------FERTILITY HORMONE CONCERNS----|Fertility concerns|IVF-related stress|Pregnancy concerns|Delivery/post-delivery concerns|Peri menopause issues|menopause issues|Hormone therapy issues|Cancer and sexuality concerns|Age and sexuality concerns|------DATING ISSUES-----|Stress with dating|Difficulty with online dating|------RACISM/SEXISM-----|Racism|Sexism|Sexual harassment|Occupational stereotypes/discrimination|-----BEHAVIORAL HEALTH ISSUES-----|Behavioral health issues|Self-Care|Hygiene issues|Sleep hygiene|Weight management|Physical activity/exercise|------SUBSTANCE USE ISSUES----|Substance use concerns|Alcohol use concerns|Cannabis use concerns|Tobacco use concerns|-----TRAUMA ISSUES-----|Past trauma event|Recent trauma event|Sexual trauma event|Past childhood neglect|Past childhood abuse|-----STRESSOR ISSUES-----|Stressors|Stressor/coping mechanism(s)|Familial relationship distress|Work problems|Financial issues|Legal Issues|Housing issues|Parenting stress|-----MEDICAL HEALTH ISSUES-----|Medical/health concerns|Disease management|Medication concerns|Health anxiety|-----RELIGIOUS ISSUES-----|Religious/spiritual concerns"].
ENDORED SYMPTOMS
The following symptoms were endorsed: [checkbox name="cb9" value="-------DEPRESSION SYMPTOMS-----|Depressed mood|Sadness|Hopeless|Appeared tearful|Crying spells|Loss of interest in activities|Loss of pleasurable in activities|Weight loss|Weight gain|Decrease in appetite|Increase in appetite|Insomnia|Difficulty falling sleeping|Trouble staying asleep|Difficulty waking too early|Increase in sleep|Observed physical slowness by others|Fatigue|Loss of energy|Feeling worthless|Inappropriate guilt|Trouble concentrating|Indecisiveness|Isolation from others|Low self-esteem|Thoughts of death without a plan|Suicidal ideation|-----PREMENSTRAUL DYSPHORIC DISORDER----|Onset of symptoms the week prior to menses|Affective lability|Mood swings|Feeling suddenly tearful|Sensitivity to rejection|Marked irritablility|Marked anger| Increased interpersonal conflicts|Feeling depressed|Feeling hopeless|Self-deprecating thoughts|Anxiety|Tension|Feeling on edge|Loss of interest in activities|Subjective difficulty in concerntrating|Marked change in appetite|Sleep changes|Feeling overwhelmed|Feeling out of control|Physical symptoms|------SOCIAL ANXIETY SYMPTOMS-----|Anxiety/Worry|Anxiety of social situations|Anxiety of social interactions|Concerns of negative evaluation by others|Fear of embarrassing self|Fear that is out of proportion to social situation|-----PANIC DISORDER/SYMPTOMS|Panic or an abrupt surge of intense fear/ discomfort|Palpitations, pundingheart, or accelerated heart|Sweating|Trembling or shaking|Shortness of breath/difficulty breathing|Feelings of choking|Chest pain/discomfort|Nausea/abdomen distress|Feeling dizzy, light-headed, or faint|Chill sensations|Heat sensations|Numbness/tingling sensations|Derealization|Depersonalization|Fear of losing control|Fear of dying|Worry about having future panic symptoms|Change in behavior to avoid panic symptom/attacks|-----GAD ANXIETY SYMPTOMS----|Excessive anxiety and worry about a number of events or activities|Difficulty controlling worry| Restlessness|Feeling on edge|Easily fatigued|Difficulty concentrating|Muscle tension|Irritability|Worry about every, routine life circumstances|Worry about job responsibilities|Worry about health|Worry about finances|Worry about the future|----SEXUALITY SYMPTOMS----|Marked infrequency of orgasm|Absence of orgasm|Reduced intensity of orgasmic sensations|Reduced interest in sexual activity|Reduced sexual interest/arousal to internal or external sexual cues|Persistent/reoccurring difficulties with vaginal penetration|Marked vulvovaginal or pelvic pain during penetration|Fear or anxiety about vulvovaginal or pelvic pain|Marked tensing or tightening of pelvic floor muscles"].

ENDORSED IMPAIRMENTS
The following areas of impairment were endorsed: [checkbox name="cb10" value="Marked increased effort for functioning|Angry outbursts|Difficulty completing tasks/responsibilities|Isolation|Noticed social withdrawal|Neglect of pleasurable activities|Increased effort required for small tasks|Difficulty getting out of bed|Neglected of self/health|Arriving late|Financial difficulties|Relationship difficulties|Conflict with others|Not completing work-related responsibilities|Decreased work productivity|Interference of job|Avoidance|Difficulty leaving home|Decrease in self-care|Sexual dysfunction|Sexual problems"].

THERAPEUTIC INTEVENTIONS USED
Provider used the following interventions: [checkbox name="cb11" value="-----MOOD DISORDER INTERVENTIONS----|Active listening and feedback|Validated and normalized emotions|Supportive reflection|Open-ended questions|Socratic questioning|Self-disclosure|Bibliotherapy|Psychoeducation|Psychosexual education|Exploration of sexual history|----------COGNITIVE BEHAVIORL THERAPY----|Introduction to the CBT model|CBT therapy modalities|Cognitive challenging|Cognitive refocusing|Cognitive restructuring|Identification/modification of dysfunctional assumptions/biases|Identify distorted automatic thoughts|-----INTERPERSONAL INTERVENTIONS-----|Communication skills to address interpersonal concerns|Assertive communication skills|Exploration of interpersonal patterns|-----SEX THERAPY INTERVENTIONS------|Sex therapy interventions|Sensate Focus|Psychosexual education|Directed masturbation|Introduction to OMGYes.com|Discussion of sexual aids/toys/vibrators|Discussion of vaginal dilators|Exploration of self touch|Bibliotherapy|Mindfulness-based cognitive interventions|Introduction to the female sexual response cycle|Reviewed the female sexual response cycle|Review benefits of sexual aids|Discuss benefits of vibrators|Discuss the benefits of lubruation|--------GOTTMAN INTERVENTIONS----|Gottman Method Couple Therapy Interventions|Gottman Love maps|Psychoeducation on building fondness and admiration|Turning toward instead of away|Psychoeducation about increasing awareness of emotional bids|Identifying the Four Horsemen|Encouraging a gental approach|Psychological soothing for flooding|Establishing formal and informal ritual of connection|Process the aftermath of an argument or regrettable incident|Exlpore pattern of closeness and distance|Explore communication cycle|Observe and provide feedback on Couple communication|Exploration of family of origin /dynamics |-----DBT INTERVENTIONS----|DBT/Emotion regulation skills|DBT/Distress tolerance skills|DBT/Interpersonal effectiveness skills|Exploration of coping patterns|Exploration of emotions|Exploration of relationship patterns|Exploration of maladaptive cyclical patterns|Interpersonal Interventions|Interactive feedback/process comments|Mindfulness Training ----|-----PAIN MANAGEMENT-----|Pain management interventions|Motivation interviewing to assess readiness for change|------SUBSTANCE USE INTERVENTIONS------|Smoking cessation interventions|Alcohol use interventions|-----BEHAVIOR HEALTH INTERVENTIONS-------|Behavioral health interventions|Sleep hygiene interventions|Behavioral activation|SMART Goals|---STRESS MANAGEMENT-----|Stress management interventions (e.g., deep breathing)| Stress management interventions (e.g., PMR)| Stress management interventions (e.g., deep breathing, PMR)|Subjective Unit of Distress (i.e., SUDs)|Practiced progressive muscle relaxation|Guided imagery|Diaphragmatic breathing"].

TREATMENT PROGRESS/PROGRESS TOWARDS TREATMENT GOALS
Client progress in achieving psychotherapy goals is best assessed as - [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 excalation in symptoms|minimal|improving|stable"] - as evidenced by Client self-report, behavior, and engagement.

ADDITIONAL SESSION INFORMATION
[textarea name="variable_10" default="N/A"]

HOMEWORK
[textarea name="variable_2" default=""]

RISK FACTORS
[checkbox name="cb13" value="No SI/HI indicated|No SI/HI reported|SI/HI denied|----------|Suicidal Ideation|No SI reported|SI Denied|Endorsed Suicidal Ideation|Endorsed Non-suicidal Morbid Ideation|Endorsed Active Suicidal Ideation with a Method but without Plan or Intent to Act|Endorsed Suicide Attempt|Endorsed Nonsuicidal Self-Injury|----------|No homicidal ideation reported|Homicidal ideation denied|Endorsed Homicidal Ideation|Endorsed Non-Homicidal Morbid Ideation|Endorsed Active Homicidal Ideation with a but without Plan or Intent to Act|Endorsed Homicidal Attempt"]

MENTAL STATUS EXAM
Orientation: [select name="MSE_1" value="Alert and oriented X4|unable to assess due to cognitive impairment"]; Affect: [select name="MSE_2" value="Full range|Flat|Tearful at times|Flat, tearful & congruent with depressed & anxious mood|Appropriate to mood and thoughts|Inapporpriate to mood and thoughts|Restricted in range and mood congruent"]; Observations: [select name="MSE_3" value="WNL|Crying|Mild agitation when discussing stressor|Moderate agitation when discussing stressor|Occasional yawning|left room"]; Speech: [select name="MSE_4" value="WNL|Normal rate and rhythm, not pressured|Pressured at times|soft"]; Behavior: [select name="MSE_5" value="WNL|Left room to use bathroom"]; Thought process: [select name="MSE_6" value="WNL|Logical, linear, goal directed|circumstantial|Circumstantial but redirectable|Tangential"]; SI/HI: [select name="MSE_7" value="Not indicated|denied|SI endorsed/HI denied"]

FOLLOW-UP PLAN:
[checkbox name="cb14" value="RTC in 1 week to assess mood/functioning, review homework, and goal setting|RCT in 1 week to assess relationship distress, review homework, and goal setting|RTC in 1-2 weeks to assess mood/functioning, review homework, and goal setting|RTC in 1-2 weeks to assess relationship distress, review homework, and goal setting|RTC in 1 month to assess mood/functioning, review homework, and termination planning|Client will contact Provider to schedule next session.|Provider will contact Client to schedule next session."]

AGENDA:


ASSESSSMENTS, SCREENERS, & SCORING

UPDATE:


SESSION ISSUES/TOPICS DISCUSSED
The following tropics/concerns were discussing in session: .
ENDORED SYMPTOMS
The following symptoms were endorsed: .

ENDORSED IMPAIRMENTS
The following areas of impairment were endorsed: .

THERAPEUTIC INTEVENTIONS USED
Provider used the following interventions: .

TREATMENT PROGRESS/PROGRESS TOWARDS TREATMENT GOALS
Client progress in achieving psychotherapy goals is best assessed as - - as evidenced by Client self-report, behavior, and engagement.

ADDITIONAL SESSION INFORMATION


HOMEWORK


RISK FACTORS


MENTAL STATUS EXAM
Orientation: ; Affect: ; Observations: ; Speech: ; Behavior: ; Thought process: ; SI/HI:

FOLLOW-UP PLAN:


Result - Copy and paste this output:

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