individual psychoTherapy telehealth

Subjective: 

The client reported feeling "[text name="mood" default="OK"]", as [select name="variable_1" value="she|he|they"] subsequently 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 throughout session."]


Assessment: 

The session focused on[textarea name="themes" default="rapport building and reviewing information provided during the intake session."] The SC provided supportive therapy while orienting the client to the therapeutic process.

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 [textarea name="focus" default="developing the therapeutic relationship and goals for therapy."]






[comment memo="------"]

SC 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. SC used open-ended questions to assist client in exploring the problem further, and SC assessed client's understanding and previous barriers. SC provided clarification and support as needed. 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 for change. SC 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'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, behavior, and engagement.