Individual Adult Therapy Session Note – Insurance Adherent

Psychiatry & Psychology
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[text name="therapist" default="Therapist Name:"]
[textarea name="therapist" default=""]

[text name="therapist_1" default="Practice Name:"]
[textarea name="therapist_1" default=""]

[text name="therapist_2" default="Practice Address:"]
[textarea name="therapist_2" default=""]

[text name="therapist_3" default="Phone Number:"]
[textarea name="therapist_3" default=""]

[text name="therapist_4" default="NPI Number:"]
[textarea name="therapist_4" default=""]

[text name="client" default="Client Initials:"]
[textarea name="client" default=""]

[text name="client_1" default="Client DOB:"]
[textarea name="client_1" default=""]

[text name="client_2" default="ICD10 Code:"]
[comment memo="Diagnosis F Code(s) and Description(s):"]
[textarea name=client_2" default=""]

[text name="session" default="Date of Service"]
[date name="session" default="06/23/2022"]

[text name="session_1" default="Session Type:"]
[select name="session_1" value="Individual|Family|Group| Crisis"]

[text name="session_2" default="Session Length:"]
[select name="session_2" value="30+min|45+min|53+min|60+min|90+min"]

[text name="session_3" default="Session Time:"]
[comment memo="Start and End Time of Session:"]
[textarea name="session_3" default=""]

[text name="session_4" default="CPT Code:"]
[select name="session_4" value="90791 (Initial Eval)|90832 (30+min)|90834 (45+min)|90837 (53+min)|90847 (Family)| 90839 (Crisis 30-74min)|90840 (Crisis add 30min)"]

[text name="session_5" default="Add CPT Code:"]
[comment memo="Add on CPT Code if needed:"]
[textarea name="session_5" default=""]

[text name="mse" default="MSE"]

[text name="mse_1" default="Appearance:"]
[checkbox name="mse_1" value="Appropriately Dressed|Appropriately Groomed|Well Dressed|Well Groomed|Casually Dressed|Disheveled|Poorly Groomed|Inappropriate to Environment/Event|HyperSexualized Appearance"]
[comment memo="Additional Notes if Needed:"]
[textarea name="mse_1" default=""]

[text name="mse_2" default="Affect:"]
[checkbox name="mse_2" value="Mood Congruent|Euphoric|Euthymic|Labile| Hostile|Guarded|Evasive|Fearful|Anxious|Dysphoric"]
[comment memo="Additional Notes if Needed:"]
[textarea name="mse_2" default=""]

[text name="mse_3" default="Mood:"]
[checkbox name="mse_3" value="Euthymic|Happy|Euphoric|Elevated|Apathetic|Labile|Angry|Suspicious|Fearful|Anxious|Dysthymic|Dysphoric|Depressed"]
[comment memo="Additional Notes if Needed:"]
[textarea name="mse_3" default=""]

[text name="mse_4" default="Behavior:"]
[checkbox name="mse_4" value="Appropriate Eye Contact|Poor Eye Contact|Intense Gaze/Unblinking|Tearful|Psychomotor Agitation|Sluggish|Cooperative|Guarded|Evasive|Appropriate Speech|Rapid Speech|Canned Speech|Slurred Speech|Monotone Speech|Paucity of Speech|High-pitched Speech|Sing-Song Speech|Does Not Appear Under the Influence|Appears Under the Influence"]
[comment memo="Additional Notes if Needed:"]
[textarea name="mse_4" default=""]

[text name="mse_5" default="Thought Process:"]
[checkbox name="mse_5" value="WNL|Linear|Goal Directed|Disorganized|Flight of Ideas|Circumstantial|Tangential|Loose Associations|Racing"]
[comment memo="Additional Notes if Needed:"]
[textarea name="mse_5" default=""]

[text name="mse_6" default="Thought Content:"]
[checkbox name="mse_6" value="WNL|Appropriate|Delusions (Granduer)|Delusions (Persecution)|Delusions (Bizarre)|Hallucinations (Auditory)|Hallucinations (Visual)|Phobias|Obsessions|Rumination"]
[comment memo="Additional Notes if Needed:"]
[textarea name="mse_6" default=""]

[text name="mse_7" default="Orientation:"]
[checkbox name="mse_7" value="WNL|Time|Place|Situation"]
[comment memo="Additional Notes if Needed:"]
[textarea name="mse_7" default=""]

[text name="mse_8" default="Judgement:"]
[checkbox name="mse_8" value="Good|Fair|Poor"]
[comment memo="Additional Notes if Needed:"]
[textarea name="mse_8" default=""]

[text name="mse_9" default="Sleep:"]
[checkbox name="mse_9" value="Good|Fair|Poor|No Changes|Did Not Report"]
[comment memo="Describe Sleep Habits or Changes:"]
[textarea name="mse_9" default=""]

[text name="mse_10" default="Appetite:"]
[checkbox name="mse_10" value="Good|Fair|Poor|No Changes|Did Not Report"]
[comment memo="Describe Eating Habits or Changes:"]
[textarea name="mse_10" default=""]

[text name="safety_1" default="Suicidal Ideation:"]
[checkbox name="safety_1" value="Denies Suicidal Ideation|Reports Suicidal Ideation|Denies Suicidal Behaviors|Reports Suicidal Behaviors|Contracts for Safety|Does Not Contract for Safety"]
[comment memo="Describe Ideation/Behavior if Reported and Safety Plan Actions Taken:"]
[textarea name="safety_1" default=""]

[text name="safety_2" default="Self-Harm:"]
[checkbox name="safety_2" value="Denies Self-Harm Thoughts|Reports Self-Harm Thoughts|Denies Self-Harm Behaviors|Reports Self-Harm Behaviors|Contracts for Safety|Does Not Contract for Safety"]
[comment memo="Describe Ideation/Behavior if Reported and Safety Plan Actions Taken:"]
[textarea name="safety_2" default=""]

[text name="safety_3" default="Homicidal Ideation:"]
[checkbox name="safety_3" value="Denies Homicidal Ideation|Reports Homicidal Ideation|Denies Homicidal Behaviors|Reports Homicidal Behaviors|Contracts for Safety|Does Not Contract For Safety"]
[comment memo="Describe Ideation/Behavior if Reported and Safety Plan Actions Taken:"]
[textarea name="safety_3" default=""]

[text name="symptoms" default="Symptoms:"]
[checkbox name="symptoms" value="Grief/Loss|Feelings of Guilt/Shame|Helplessness|Hopelessness|Feeling of Low Self Worth|Feeling Numb|Suicidal Ideation|Self-Harm|Homicidal Ideation|Aggression (Verbal)|Aggression (Physical)|Rage|Anger|Frustration|Anxiety|Panic Attacks|Elevated Heart Rate|Heart Palpitations|Muscle Tension|Trembling/Shaking|Sweating|Shortness of Breath|Increased Startle Response|Racing Thoughts|Rumination|Obsessive Thoughts|Compulsive Behaviors/Thoughts|Fear|Phobia|Nightmares|Avoidance|Depression|Sad or Down Most Days of the Week|Tearful|Anhedonia|Anergia|Fatigue|Difficulty with Concentration/Memory|Difficulty Completing Tasks
|Difficulty Following Directions|Difficulty Completing ADL's|Lack of Engagement|Isolation|Labile Mood|Mania|HyperVerbal|Increased Sexual Activity|Decreased Sexual Activity|Increased Spending|Risky Behaviors|Gambling|Substance Use|Hyperactive|Hypoactive|Hallucinations (Auditory)|Hallucinations (Visual)| Delusions (Grandeur)|Delusions (Persecution)|Delusions (Bizarre)|Treatment Non-Compliant|Excessive Sleeping|Difficulty Sleeping|Increased Appetite|Loss of Appetite|Binge Eating|Restrictive Eating|Purging|Excessive Dieting|Excessive Exercise|Body Dysmorphia|Gender Dysmorphia|Other"]
[comment memo="Describe Other Reported Symptoms or Additional Symptom Information:"]
[textarea name="symptoms" default=""]

[text name="note" default="SOAP Note"]

[comment memo="Current Complaints/Session Focus:"]
[textarea name="note_1" default=""]

[comment memo="Reported Symptoms/Changes:"]
[textarea name="note_2" default=""]

[comment memo="Client Activity Level (Completion of ADL's, Engagement in Activities, Hobbies, Work, Education, Home Environment):"]
[textarea name="note_3" default=""]

[comment memo="Current Stressors (Incl. Any Reported Changes, Positive or Negative Coping Skills, Etc.):"]
[textarea name="note_4" default=""]

[comment memo="Progress/Improvement Since Last Session:"]
[textarea name="note_5" default=""]

[comment memo="Modality/Skills Used in Session (Gained Insight & Understanding, Explored Narrative Therapy, Taught and Practiced DEARMAN Skill, Reviewed Homework, Etc):"]
[textarea name="note_6" default=""]

[comment memo="Statement of Medical nNecessity for Continued Treatment:"]
[textarea name="note_7" default=""]

[comment memo="Assessment and Clinical Impression of Client Needs, Complaints, and Progress:"]
[textarea name="note_8" default=""]

[comment memo="Plan to Address (Referrals, Homework, Goals, Next Session Focus/Date):"]
[textarea name="note_9" default=""]






















Diagnosis F Code(s) and Description(s):












Start and End Time of Session:






Add on CPT Code if needed:






Additional Notes if Needed:




Additional Notes if Needed:




Additional Notes if Needed:




Additional Notes if Needed:




Additional Notes if Needed:




Additional Notes if Needed:




Additional Notes if Needed:




Additional Notes if Needed:




Describe Sleep Habits or Changes:




Describe Eating Habits or Changes:




Describe Ideation/Behavior if Reported and Safety Plan Actions Taken:




Describe Ideation/Behavior if Reported and Safety Plan Actions Taken:




Describe Ideation/Behavior if Reported and Safety Plan Actions Taken:




Describe Other Reported Symptoms or Additional Symptom Information:




Current Complaints/Session Focus:


Reported Symptoms/Changes:


Client Activity Level (Completion of ADL's, Engagement in Activities, Hobbies, Work, Education, Home Environment):


Current Stressors (Incl. Any Reported Changes, Positive or Negative Coping Skills, Etc.):


Progress/Improvement Since Last Session:


Modality/Skills Used in Session (Gained Insight & Understanding, Explored Narrative Therapy, Taught and Practiced DEARMAN Skill, Reviewed Homework, Etc):


Statement of Medical nNecessity for Continued Treatment:


Assessment and Clinical Impression of Client Needs, Complaints, and Progress:


Plan to Address (Referrals, Homework, Goals, Next Session Focus/Date):

Result - Copy and paste this output:

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