individual psychoTherapy telehealth

Psychiatry & Psychology
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Subjective:

The client reported feeling [text name="subjective Description or details about mood" default="OK"], as [select name="variable_1" value="she|he|they"] stated, "[textarea name="QUOTE"]."


Objective:

The client joined the Zoom platform [select name="timing" value="early|on time|late" default="on time"]for the scheduled Telehealth appointment session. [select name="variable_1" value="She|He|They"] was [select name="dress" value="appropriately dressed|not appropriately dressed"] in [text name="type of clothing" default="casual clothing"].

The client was oriented [text name="oriented" default="x4"], and [text name="risk" default="denied"] any current suicidal and/or homicidal ideations, plans, or intents. [select name="variable_1" value="Her|Him|Their"] mood was observed as [text name="mood" default="euthymic "] and affect appeared [text name="affect" default="appropriate"]. [select name="variable_1" value="She|He|They"] was [text name="attention" default="alert"] and [text name="goals" default="goal driven"], as reflected by [textarea name="behavior" default="her willingness to participate in elaborative conversation with SC."]


Assessment:

The session focused on[textarea name="themes" default="rapport building and reviewing information provided during the intake session. SC provided supportive therapy while re-orienting the client to the therapeutic process. Client was tearful when discussing family relationships but showed a willingness to participate in therapy."]

The SC introduced
[textarea name="treatment" default="grounding and mindfulness exercises to the client through the use of worksheets/handouts and an interactive guided audio video activity."]

The client reported [textarea name="response" default="to have enjoyed the interventions presented and expressed a wiliness to practice such activities between sessions."]


Plan:

The next session is schedule for[date name="date" default="07/12/2021"] at [text name="time" default="1:00 PM"] and will focus on developing[textarea name="focus" default="the therapeutic relationship and goals for therapy."]






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[comment memo="Writer invited client to initiate session by asking client to share their current status. Client reported to [textarea name="variable_5" default=""]

Writer demonstrated active listening skills, and when client finished reporting self-identified status, this writer used reflection, and clarified client's priorities and readiness. Using a collaborative approach to agenda map with client identifying [text name="variable_6" default=""] as being an area which could be a primary focus for this session.

Writer used open-ended questions to assist client in exploring the problem further, and this writer assessed client's understanding and previous barriers. Writer provided affirmations and built confidence through ask-tell-ask, where praise was given to support [comment memo="Praise: specify at least 1 positive event, attitude or strength of client identified"][text name="praise" default=""].

Client was asked to consider incremental changes to address their reported barriers. Client was able to identify [text name="variable_7" default=""] as a possibility. Writer used scaling questions to assess readiness and commitment and worked collaboratively with client to develop a plan that includes adequate structure, accountability, benchmarks and rewards. Client and this writer developed homework for next session.

A: Client appears to be in [select name="variable_8" value="pre-contemplative|preparatory|action|maintenance"] stage of change as evidenced by [textarea name="variable_9" default=""]. Client's progress in achieving treatment goals is best assessed as "[checkbox name="progress" value="minimal|inconsistent|progressing|improving|stable"]" as evidenced by client's self-reports, drug screen results, behavior and engagement."]
Subjective:

The client reported feeling , as stated, "."


Objective:

The client joined the Zoom platform for the scheduled Telehealth appointment session. was in .

The client was oriented , and any current suicidal and/or homicidal ideations, plans, or intents. mood was observed as and affect appeared . was and , as reflected by


Assessment:

The session focused on

The SC introduced


The client reported


Plan:

The next session is schedule for at and will focus on developing






------



Writer demonstrated active listening skills, and when client finished reporting self-identified status, this writer used reflection, and clarified client's priorities and readiness. Using a collaborative approach to agenda map with client identifying as being an area which could be a primary focus for this session.

Writer used open-ended questions to assist client in exploring the problem further, and this writer assessed client's understanding and previous barriers. Writer provided affirmations and built confidence through ask-tell-ask, where praise was given to support Praise: specify at least 1 positive event, attitude or strength of client identified.

Client was asked to consider incremental changes to address their reported barriers. Client was able to identify as a possibility. Writer used scaling questions to assess readiness and commitment and worked collaboratively with client to develop a plan that includes adequate structure, accountability, benchmarks and rewards. Client and this writer developed homework for next session.

A: Client appears to be in stage of change as evidenced by. Client's progress in achieving treatment goals is best assessed as " " as evidenced by client's self-reports, drug screen results, behavior and engagement."]

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