Individual psychotherapy Telehealth

Psychiatry & Psychology
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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.
Subjective:
The client stated, "."

Objective:
The client joined the Zoom platform 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.

.

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:.
Last drug screen: and results reported as .

D: Client came to office to meet with this writer .

Writer invited client to initiate session by asking client to share their current status. Client reported to.

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.

Plan:
The next session is scheduled for . Client reports commitment to 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.

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