Initial Session

Psychiatry & Psychology
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Client Name:
[text name="variable_1" default="sample text"]
Date of Service:
[text name="variable_1" default="sample text"]
Session #:
[select name="variable_23" value="Initial|Discharge|"]
Session Start/Stop Times:
[text name="variable_1" default="sample text"]
Session Format:
[select name="variable_1" value="Remote Video|Remote Telephone|Remote Written"]
Other Individuals Present:
[select name="variable_25" value="Yes|No, Client Only|"]
Consent on File for Other Individuals Present: [select name="variable_25" value="Yes|N/A|"]
Referral Source: Better Help
Address of Present Location:
[text name="variable_1" default="sample text"]

Client arrived [select name="variable_1" value="on time|late|"] for scheduled [select name="variable_23" value="Initial|Ongoing|Discharge|"] individual therapy session. Client provided acknowledgment and consent to engage in a remote [select name="variable_1" value="telephone|video|written|"] session".

Client reported that symptoms [select name="variable_19" value="are|have|"] [select name="variable_18" value="stable|not changed|changed|"]and are currently of [select name="variable_20" value="mild|moderate|severe|"] concern. Client reported that [select name="variable_1" value="he|she|they"] feels [text name="variable_1" default="sample text"]. Client [select name="variable_1" value="reported|denied|"] noticeable changes in feelings, emotions, behaviors, or responses since last session [text name="variable_1" default="sample text"]. Client [select name="variable_22" value="reported|denied|"] experiencing significant events since last session [text name="variable_1" default="sample text"].

Current Assessment of Status & Functioning
[select name="variable_5" value="100-91 Superior functioning in a wide range of activities|90-81 Absent or minimal symptoms|80-71 Symptoms are transient and expectable reactions to psychosocial stressors or slight impairment in functioning|70-61 Mild symptoms or impairments in functioning|60-51 Moderate symptoms or impairments in functioning|50-41 Serious symptoms or impairment in functioning|"]
Client is [checkbox name="variable_1" value="Orientated to person, place, time, and event|Not orientated to person, place, time, and event|Not orientated to place, time, or event|Not orientated to time and event|Not orientated to event|Obtunded|Disoriented|"]. Behavior observations indicate that client maintained [checkbox name="variable_2" value="appropriate posture and mannerisms|good eye contact|fair eye contact|avoidant eye contact|shifting eye contact|periods of staring in the distance|psychomotor agitation|psychomotor retardation. Client showed
[select name="variable_17" value="symptoms of|No apparent psychological distress|"]|Akathisia|Catatonia|Dystonia|Tremor|Mild psychological distress|Moderate psychological distress|Acute psychological distress|"].Client appeared [checkbox name="variable_3" value="appropriately dressed and groomed with no visible indication of impaired hygiene.|Disheveled|Bizarre Style|Visible indication of impaired hygiene|Underdressed|Overdressed|Average weight|Thin|Overweight|Obese|Underweight|Appears stated age|Appears younger than chronological age|Appears older than chronological age|"].
Attitude: [checkbox name="variable_4" value="Antagonistic|Hostile|Silent|Inappropriate boundaries|Seductive|Playful|Ingratiating|Evasive|Guarded|Defensive|Evasive|Suspicious|Attentive|Charming|Childish|Communicative|Controlling|Critical|Distant|Eager to Please|Engaged|Entitled|Flattering|Interactive|Sullen|Manipulative|Contemptuous|Demanding|Withdrawn|"].
Affect: [checkbox name="variable_6" value="Full range of affect|Normal range|Normal Intensity|Appropriate to context|Congruent to mood|Incongruent to mood|Agitated|Angry|Animated|Anxious|Apathetic|Anhedonic|Dysphoric|Blunted|Broad|Detached|Elated|Euphoric|Euthymic|Even|Expansive|Flat|Hyper-energized|Indifferent|Irritable|Labile|Restricted|Sad|"].
Speech: [checkbox name="variable_7" value="Clear|Coherent|Logical|Normal rate and flow|Normal volume|Normal rhythm|Normal content|Accest/dialect|Clanging|Echolalia|Latency|Loud|Soft|Neologism|Perseveration|Pressuresd|Paucity|Rapid|Slowed|Spontaneity|Stuttering|Slurred|Mumbled|Lisping|Inaudible|Incoherent|Long pauses|Responds only to questions|Scant|Mute|Verbose|Repetitive"].
Thought Content: [checkbox name="variable_8" value="Within normal limits|Thought withdrawal|Thought insertion|Paranoia|Thought broadcast|Suspiciousness|Grandiose delusions|Somatic delusions|Delusional guilt|Nihilistic delusions|Ideas of reference|Ideas of inference|Magical thinking|Obsession|Preoccupation|Rumination|Phobia|"].
Thought form and flow: [checkbox name="variable_9" value="Logical|Linear|Goal-directed|Relevant|Not logical|Not relevant|Not linear|Not goal-directed|Past orientated|Scattered|Impoverished|Racing thoughts|Circumstantial|Perservations|Flight of ideas|Illogical|Incoherent|Neologism|Distractable|Tangential|Overvalued ideas|Excited|Poverty of thought|Word salad|Clang associations|Slow reaction|Rapid reaction|Doubting|Indecisive|Blocking|Spontaneous|Pressured|Fragmented|Loose associations|"].
Thought Perception: [checkbox name="variable_10" value="Within normal limits|Illusions|Hallucinations|Denationalization|Derealization/Depersonalization"]
Cognition/Memory: [checkbox name="variable_11" value="Within normal limits|Grossly intact|Below average|Above average|Average|Alert|Drowsy|Lethargic|No apparent memory impairment|Impaired memory|No apparent concentration impairment|Impaired concentration|No apparent attention impairment|Impairment in attention|Normal ability to abstract|Difficulty with abstract thought|Inability for abstract thought"].
Insight: [checkbox name="variable_12" value="Full awareness/understanding of situation|Partial awareness/understanding of situation|Poor to no awareness/understanding of situation"]
Judgment: [select value="good|fair|poor"].
Additional information: [textarea cols="80" rows="3" default= "No additional information."]

Primary Therapeutic Interventions
Therapist utilized psychodynamic tools and techniques including [checkbox name="variable_1" value="Interpreting mental and emotional processes|Probing for recurring patterns in the client's subconscious mind|Guiding the client through the examination of unresolved conflicts and significant events in the client's past|Identifying themes in the client's emotions, thoughts, and beliefs|Assisting client to gain insight about the client's current self|Attempts to clarify what is consciously going on in the client's mind|Supporting the client to bring into awareness nonverbal aspects of the client's behavior|Exploring the client's use of language|Encouraging introspection about childhood experiences as influences in their current behaviors|Exploring the client's representation of self and other|Analyzing conflicts between motivational and affective states|Highlighting the client’s emotional and interpersonal patterns|Providing interactional experiences that serve corrective developmental purposes|Observation and clarification of difficult or contradictory thoughts and feelings|Joint exploration of unconscious meanings and motivations|Exploration of concerns and issues in the client’s world|Exploration of the relational dynamics occurring between therapist and client|Mirroring the client's emotional responses"]

Secondary Therapeutic Interventions
Therapist utilized cognitive-behavioral tools and techniques including
[checkbox name="variable_1" value="Restructuring and reframing|Guided discovery|Relaxation and stress reduction techniques|Creating actionable goals that promote problem-solving|Assisting client to identify undesirable or inappropriate behaviors|Validating positive behaviors|Supporting the client to bring into awareness nonverbal aspects of the client's behavior|Exploring the client's use of language|Encouraging introspection about childhood experiences as influences in their current behaviors|Exploring the client's representation of self and other|Analyzing conflicts between motivational and affective states|Highlighting the client’s emotional and interpersonal patterns|Providing interactional experiences that serve corrective developmental purposes|Observation and clarification of difficult or contradictory thoughts and feelings|Joint exploration of unconscious meanings and motivations|Exploration of concerns and issues in the client’s world|Exploration of the relational dynamics occurring between therapist and client|Mirroring the client's emotional responses|"]



development of insight into unconscious motivations, defenses, and interpersonal patterns|"]


Client's Response to Interventions
[checklist name="variable_1" value="option A|option B|option C"]

Assessment of Progress
Client reports [select name="variable_1" value="choice A|choice B|choice C"] towards achieving their desired treatment outcomes.

Plan
[textarea name="variable_1" default="sample text"]
Client Name:

Date of Service:

Session #:

Session Start/Stop Times:

Session Format:

Other Individuals Present:

Consent on File for Other Individuals Present:
Referral Source: Better Help
Address of Present Location:


Client arrived for scheduled individual therapy session. Client provided acknowledgment and consent to engage in a remote session".

Client reported that symptoms and are currently of concern. Client reported that feels . Client noticeable changes in feelings, emotions, behaviors, or responses since last session . Client experiencing significant events since last session .

Current Assessment of Status & Functioning

Client is . Behavior observations indicate that client maintained |Akathisia|Catatonia|Dystonia|Tremor|Mild psychological distress|Moderate psychological distress|Acute psychological distress|"].Client appeared .
Attitude: .
Affect: .
Speech: .
Thought Content: .
Thought form and flow: .
Thought Perception:
Cognition/Memory: .
Insight:
Judgment: .
Additional information:

Primary Therapeutic Interventions
Therapist utilized psychodynamic tools and techniques including

Secondary Therapeutic Interventions
Therapist utilized cognitive-behavioral tools and techniques including




development of insight into unconscious motivations, defenses, and interpersonal patterns|"]


Client's Response to Interventions


Assessment of Progress
Client reports towards achieving their desired treatment outcomes.

Plan

Result - Copy and paste this output:

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