Follow Up Note JD

[comment memo="First Name"][text name="first_name" default=""] ([select name="gender_ID" value="Client|She|He|They|Person|Patient"])
START: [text name="Start" default="" ] -- END: [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]
CPT: [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 utilized."]. [textarea name="variable_17" default=" "][/conditional]
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MEDICAL/LEGAL CHANGES OR CONCERNS: [textarea name="Med_Changes" default=" None reported."]
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="affect_text" 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 conguent with content.|Mood is incongruent with content."][text name="mood_text" default=" "]
Thought processes and content are [select name="Thought_Process" value="goal directed and logical|disorganized|xxxxxx"]. [text name="thought_text" 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."][textarea name="risk_text" 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 planhigher 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="morerisk_text" default=" "][/conditional]
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FUNCTIONAL STATUS
Relational: [select name="Rel" value="intact|variably impaired|impaired"]
[textarea name="rel_text" default=""]
Occupational/School: [select name="Occ_Edu" value="intact|variably impaired|impaired"]
[textarea name="occ_edu_text" default=""]
Physical: [select name="Phy" value="intact|variably impaired|impaired"]
[textarea name="phy_text" default=""]
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CURRENT CONCERNS: [checkbox name="concerns_check" 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"]. [textarea name="concernstext" default="Client reports"][comment memo="quote from patient about how things are going"]
•
[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="var" default=""][comment memo="addt'l attendees; client location if telehealth"] [var name="gender_ID"] [select name="Presentation" value="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 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"][textarea name="presentation_text" default=""]
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SESSION THEMES: [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"] [textarea name="themewords" default=""]
[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|******"][textarea name="themewords2" default=""][/conditional]
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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|xxxxxx"][textarea name="session_goals" default=" "]
•
CLINICAL INTERVENTIONS: [checkbox name="Interventions" value="We focused on empathetic validation, reassurance, and further exploring and naming emotions/experiences with the purpose of enhancing ego function, supporting mature defenses, and fostering insight into psychosocial stressors.|We worked on cognitive restructuring by challenging automatic negative thoughts that contribute to depression and anxiety, and identified cognitive distortions also influencing mood.|We reviewed the relationship between thoughts, feelings, and behaviors, and considered how to address ones feelings by modifying the other two constructs.|The patient and I worked on emotional experiencing and processing of feelings that arise around certain stressors or events, that historically are pushed down, buried, or otherwise repressed. We considered the pitfalls of emotional avoidance including the onset or worsening of depression and anxiety. |We explored the patients stressors and frustrations. I validated these frustrations and empathized with the experience. We explored some ways to improve distress/frustration tolerance, including healthy distraction (with enjoyable activities, focusing on others, counting, and tasks/chores), radical acceptance, self-soothing techniques, mindfulness, coping thoughts, and self-affirming thoughts.|We explored fear of abandonment which is chronic and longstanding. Discussed how the fear of abandonment does not make healthy decisions whereas the logical and more thoughtful does, and we want to recognize who is making decisions for them at different times as a way of developing cognitive dissonance from the thoughts, impulses, and decisions that fear of abandonment self makes|We explored tendencies towards perfectionism, and how this inherently implies a binary way of thinking, in which one has either been perfect or failed. We considered the inauthenticity of this thinking and how there is a spectrum between these points. We further considered how people make opinions of us based upon a number of interactions or data points such that an average is taken and the opinion is based upon this. Accordingly, one can have several positive data points which allows room to make some mistakes or have negative data points without drastically distorting the perception of us.|We worked on problematic reactions used to deal with extremely intense emotions and increasing understanding of what leads to problematic behaviors or responses to these emotions|We worked on relationship issues such as interpersonal conflict, role transitions, or grief that may contribute to the development or continuation of mental health problems or symptoms.|We worked on unconscious influences and feelings that may be related to past events and interactions which allows for better self awareness, change, and recovery.|Exploration and healthy expression of grief related to the loss of a loved one or relationship.|We utilized Internal Family Systems treatment methods ('parts work')|Identification and exploration of parts and their roles.|Exploration of parts that self has a tendency to blend with and identification of ways to unblend and separate from these parts. |xxxxxx"][textarea name="intervention_text" 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"]. [textarea name="moreinterventiontext" default=" "][/conditional]
[select name="mitigateornah" 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.|"][textarea name="mitigate_text" default=" "]
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PROGRESS/RESPONSE: [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."][textarea name="progress_text" 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"].[textarea name="moreprogress_text" default=" "][/conditional][textarea name="evenmoreprogress_text" default=" "][comment memo="quote from pt about how session went"]
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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"][textarea name="plan_text" 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"][textarea name="followup_text" 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"][textarea name="ending_text" default=" "]
First Name ()
START: -- END: (Duration: score1=((End)-(Start))-40 minutes)
show code guide
CPT:
show add-on codes * extended session length


MEDICAL/LEGAL CHANGES OR CONCERNS:
AFFECT:
MOOD:
Thought processes and content are .
RISK ASSESSMENT: expand safety

FUNCTIONAL STATUS
Relational:

Occupational/School:

Physical:


CURRENT CONCERNS: .quote from patient about how things are going

first_name arrived for session. addt'l attendees; client location if telehealth gender_ID

SESSION THEMES:
Conditional Themes List Relational Themes Trauma Themes Identity Themes Process Themes Grief/Mourning/Loss Themes Adjustment Themes Daily Life Themes


SESSION GOALS:

CLINICAL INTERVENTIONS: expand more interventions



PROGRESS/RESPONSE: expand more progress and RTI options
quote from pt about how session went

PLAN: expand ongoing plan options

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