Individual psychotherapy Telehealth
Subjective: The client stated, "[text name="quote" default=""]." Objective: The client joined the Zoom platform [select name="timing" value="early|on time|late"]for the scheduled Telehealth session. She was appropriately dressed in casual clothing and was oriented. The client denied any suicidal/homicidal ideations. Her mood was depressed, and affect was appropriate. She appeared alert, attentive, and goal driven, as reflected by her eagerness to participate/engage in elaborative conversation with SC. [checkbox name="reason" value="to engage for monthly counseling|at the request to see counselor"]. Assessment: The session focused on 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 grounding and mindfulness exercises to the client through the use of worksheets/handouts and an interactive guided audio video activity. The client reported that she enjoyed the interventions presented and expressed a wiliness to practice such activities between sessions. All items used during session were also provided to the client via email. Last Medical Appointment:[date name="variable_2" default="03/28/2019"]. Last drug screen:[date name="variable_3" default="03/28/2019"] and results reported as [select name="variable_4" value="normal|abnormal"]. D: Client came to office to meet with this writer [checkbox name="reason" value="to engage for monthly counseling|at the request to see counselor"]. 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. Plan: The next session is scheduled for [date name="variable_10" default="07/12/2021"]. Client reports commitment to [text name="v" default=""] prior to next session. This writer will remain available to offer ongoing resources if client needs support between session. The SC will contact the client on 08-31-2020 to schedule the next session that will continue to focus on developing the therapeutic relationship and goals for therapy.
There are 17 form elements.