Psychiatry & Psychology
approximately 14 views in the last month.
[comment memo="Patients first name"] [text name="variable_1" default=""]

[comment memo="he or she"] [checkbox name="variable_1" value="he|she"]

[comment memo="his or her"] [checkbox name="variable_2" value="his|her"]

[comment memo="him or her"] [checkbox name="variable_3" value="him|her"]

[comment memo="Tick as many boxes to describe what you worked on today:"]


[checkbox name="acaperf" value="is failing tests and assignments|struggles to keep up with peers|feels that the classes are too difficult|extracurricular activities are interfering with academic performance|lacks order and system in study|is disorganized and careless|is rarely or never prepared|does not seek help when appropriate|copies from peers|engages in cheating or plagiarism|has poor attendance|has a poor relationship with academic staff|just doesn't enjoy school"]


[checkbox name="sofac" value="is a loner|relates poorly to others|struggles to set boundaries and be assertive|is becoming more isolative|does not fit in|feels excluded by others|is easily influenced and highly suggestible|engages in risky activities with peers|verbally criticizes peers|verbally criticizes caregivers|is over-assertive with others|does not participate in group activities|interacts inappropriately with peers|is sexually inappropriate with peers|refuses to complete work assignments|does not follow rules and procedures|is socially disruptive|engages in attention seeking behaviours|is overly demanding of attention from others|has frequent tantrums in groups|frequently acts the clown|plays pranks on others|is overly dependent on others|timid/shy/dependent/anxiety-prone|is not accepted by others|does not sustain friendships|is an object of scorn/ridicule|is scapegoated/picked on|accedes to the needs of others|lives socially isolated"]


[checkbox name="conduct" value="is verbally aggressive|frequently interrupts|is controlling of others|frequently starts fights|does not respect rights and property of others|purposely agitates/disturbs/disrupts others|is pushy and over-assertive|bullies and intimidates|frequently teases|attempts to manipulate|is overactive|is frequently inappropriate|cannot sit still and is generally restless|has numerous disciplinary offenses|is malicious|is cold and calculating|lacks empathy and warmth|is cruel and punitive|has little respect for authority|is generally considered a troublemaker|is aggressive and generally violent|is destructive of own/others property|hits caregivers|is antagonistic|is frequently disobedient|is negativistic|is oppositional|is argumentative|talks back/mouthy|is defiant of authority|refuses to help with chores|feels above the law|complies only when threatened|is needlessly stubborn|is immature relative to peers|demonstrates poor judgment|does not take responsibility for mistakes|does not own their behavior or consequences|demonstrates selective mutism|is prejudiced|is bigoted|insults others|vandalizes|engages in hate crimes|disobeys any authority|dares and provokes others|acts out|uses obscenities|has temper tantrums|falls to floor and tantrums|bangs head|has breath holding episodes|throws objects|screams|weeps|is generally destructive"]


[checkbox name="cogfac" value="is highly distractible|is vague and daydreams|is hyperactive|is inattentive|handles novel situations poorly|lacks foresight|has low frustration tolerance|is easily confused|is unable to understand tasks|frequently daydreams|has poor concentration|is averse to change|is excessively concrete|has an inflexible and rigid thinking style|has unusual and extreme beliefs|appears intellectually delayed|is often confused|is frequently forgetful|is unable to accept guidance|has speech and language difficulties|does not seem to understand instructions|has declined in cognitive performance"]


[checkbox name="motdif" value="does not try hard with difficult tasks|generally makes little effort|is content to coast along|has the ability to do better work but lacks interest|generally shows no interest in the subject matter|always needs great encouragement to complete work|gives up at first sign of difficulty|has low frustration tolerance|always seems preoccupied|is slow to respond|does not complete work assignments|does not make up for lost time|turns in assignments late|is careless with work|does not spend enough time on important tasks|is known for frequent absenteeism|is always tardy|cuts classes|avoids work|is frequently truant|avoids school|refuses to attend school|refuses to attend work"]


[checkbox name="becon" value="engages in alcohol/drug/substance abuse|has encopresis|has enuresis|engages in fire setting|engages in hypochondriasis|is frequently overactive and restless|engages in self injurious behaviour|hits others|bites others|engages in head banging|has a sexual preoccupation|engages in public masturbation|demonstrates inappropriate sexual behaviors|is frequently obscene|swears|makes sexualized gestures and remarks|exhibits genitals/disrobes/public nudity|wears provocative clothing for attention|demonstrates molestation concerns|threatens others when needs aren't met|inappropriately touches others|fondles/rubs against others|engages in battery|has forced sexual intercourse|is assaultative|has raped|threatens others|is slow moving|is slow to respond|hypoactive|is restless|excessively fidgets|is constantly out of seat|is impulsive|hyperactive/overactive|thumb sucking|rocking|stereotyped movements|tics|noise or word productions|violence/aggression|struggles to regulate"]


[checkbox name="afcon" value="anxiety|depression|anxiety and depression|emotional shut down|fears|phobias|nervous habits|avoidance of particular certain things/actions/situations|anger|irritability|outbursts/rage/tantrums/meltdowns|tearfulness|sulking|whines|complains of hurt feelings|has chronic low moods|always feels flat|is joyless and anhedonic|is sad|is unhappy|is grief stricken|cries and is tearful|feels hurt by others|is easy fatigued|is apathic|feels ashamed|feels guilty|feels suicidal|has a limited range of emotions|expresses only high-intensity feelings|is emotionally overactive|is histrionic|dramatizes|plays the victim|complains of general distress|is always worrying|complains of global distress|complains of loneliness|has performance anxiety"]


[checkbox name="Seles" value="poor self-concept|low self worth|identity diffusion|gender identity concerns|poor self-efficacy|sexual orientation concerns|adoption concerns|feelings of abandonment|poor sense of belonging"]


[checkbox name="Relcon" value="has marital difficulties|has friendship problems|fears over impending breakup|emotional distress after a recent breakup|has social group difficulties|lack of interpersonal effectiveness|poor boundaries and lack of assertiveness|poor social supports|family problems|lack of interpersonal coping|is unable to make and maintain close friendships"]


[checkbox name="Lifetran" value="is unable to make life decisions|is experiencing academic / graduation delays|has retirement anxiety|unable to accept stage of life|moving house anxiety|difficulty with stage of life tasks|leaving home anxiety|leaving high school|poor life satisfaction"]


[checkbox name="Physcom" value="has eating difficulties|has starvation syndrome and associated medical problems|has struggles with obesity and associated medical problems|medical problem|has a bad injury|has a range of physical problems|has mobility problems|is dying|has been given a poor health prognosis|has poor mobility"]


[checkbox name="Subab" value="alcohol overuse|substance abuse|substance dependence|spending all available money on addictions|feeling impaired by addiction"]


[checkbox name="Selman" value="compulsive behaviours|has an uncontrolled behaviour|phobias|obsessions|thought problems|feels ashamed of normal sexual functioning|uncontrolled feelings|overt behaviour|unaware of social behavior|has a lack of leisure time|has a lack of leisure activities|is perfectionistic and procrastinates|specific performance problems|poor coping skills|struggles to make friends|has social anxiety|has cognitive difficulties"]


[checkbox name="Trau" value="reported child abuse|had a recent disturbing event|had an ACE|experienced a war / armed conflict|was a victim of crime|had a serious injury|a bad accident|was harshly attacked|an unexpected death|an unexpected loss"]


[checkbox name="Psychst" value="poverty|homeless|oppression by others|cultural dislocation|harassment|unemployment|loss of peer group|divorce|separation|job stress|bullying"]


[checkbox name="Ach" value="career|life decisions|academic underachievement|life tasks are unfulfilled|has poor life satisfaction|specific performance problems"]


[checkbox name="Indef" value="has issues which need to be further explored|wants to talk about a troubled past|has a variety of pressing concerns|everything seems to be going wrong at this time|has been avoiding problems for years but they're catching up|not sure, but wants to find out what is bothering them|has general life stress|needs to get back into a regular therapy arrangement|want to talk with someone on a regular basis|need someone to talk with about subjects on my mind|seeking psychological support"]


[checkbox name="Qual" value="want to improve the quality of life|wishes to be happier|wanting to see life in new ways"]

[comment memo="What situation is this feeling at its worst? Choose one"] [checkbox name="variable_50" value="at school|at home|surrounded by strangers|at work|at home in the evening|in bed late at night|just waking up in the morning|feeling trapped|lying in bed|at a social gathering|at any family gathering|in a sexual situation|anywhere in particular|in a romantic / sexual context|with anyone at all|with their boss|with their work colleague|with an identified bully|with anyone in authority|with their parents|with a particular teacher|with a specific family member|with specific family members|with friends|with a particular friend|with their ex-partner|with a specific individual"] [comment memo="describe the situation or name the specific person if needed"][textarea name="variable_8" default=""]

[comment memo="What cognitive distortions are apparent? Choose one"]

[checkbox name="variable_51" value="Nothing of note|filtering (selective attending)|polarization (splitting / all-or-nothing / black-and-white thinking)|over-generalization (concluding from one example)|discounting the positive (devaluing positive events)|jumping to conclusions (assuming things without evidence)|catastrophizing (always expecting the worst)|personalization (taking everything personally)|control fallacies (assuming one exerts too much or too little control)|fallacy of fairness (assuming the world should be fair)|blaming (others are responsible for how one feels)|shoulds (ironclad rules applied to oneself or others)|emotional reasoning (assuming the way one feels makes it a fact)|fallacy of change (expecting others to change if they would only apply more effort)|global labeling (using one concept to describe a complex system)|always being right (viewing ones opinions as facts)"]

[comment memo="Were there any obvious personality features in the transference? Choose one"] [checkbox name="variable_52" value="Nothing of note|Paranoid (suspicious)|Schizoid (isolative)|Schizotypal (odd)|Antisocial (hostile)|Borderline (unstable)|Narcissistic (self-interested)|Avoidant (anxious)|Dependent (passive)|Obsessive-compulsive (controlling and rigid)"]

[comment memo="What usually triggers the patient's concern - choose one"] [checkbox name="variable_53" value="Nothing of note|when the Pt recalls a past trauma|when the Pt's reputation is on the line|when the Pt perceives an injustice|when the Pt believes that others aren't following the rules|when the Pt is in a boring or under-stimulating environment|when the Pt is struggling with parenting duties|when the Pt sees a frightening event in the news|when the Pt has unpleasant thoughts of any kind|when the Pt has unpleasant feelings of any kind|when the Pt becomes aware of being all alone|when the Pt feels that everyone is watching|when the Pt feels excessive work pressure|when the Pt is in the middle of intense family friction|when the Pt feels threatened with a relationship breakup|when the Pt is not getting replies to messages|when the Pt sees hurtful messages on social media|when the Pt is ruminating on past hurts|when the Pt receives critical or judgemental comments|when the Pt feels teased or put down|when the Pt is reminded of financial pressure|when the Pt feels ignored|when the Pt feels invalidated|when the Pt experiences physical illness symptoms|when the Pt experiences unusual somatic feelings|when the Pt feels harassed|when the Pt is being yelled at|when the Pt is having interpersonal conflict of any kind|when the Pt needs to be assertive|when the Pt is around unpleasant people|when the Pt aware of certain unpleasant smells, tastes, or noises in the environment"]

[comment memo="Choose the patient's unhelpful thought that is triggered. Choose only one"] [checkbox name="variable_54" value="Patient unable to identify a particular thought|there is something wrong with me|I'm no good|I'm stupid|I'm worthless|I don't matter|I can't cope|I can't do this|I'm a failure|I'm boring|I'm better off alone|I don't need anyone|everyone leaves me|I can't be happy|I need someone to love me|everyone rejects me|If I love someone, they will leave me|the world is a dangerous place|I am not good enough|I’m different from others|I don't belong|I don't fit in|no one understands me|there is something wrong with me|I am unlovable|no one likes me|I make others feel bad|everything is my fault|I need to fix other people|I need to help others|I have to be perfect|I am selfish|I'm special|I deserve attention|everyone is stupid|I'm above the rules|I can't go wrong|I'm superior"]

[comment memo="Check one maladaptive coping behaviour"] [checkbox name="variable_55" value="Unable to identify|restrict calories|becomes over-assertive|feels the need to over-perform|avoids the situation|negatively ruminate|over-exercise|immerse in fantasy|actively deny the problem|become increasingly passive and helpless|renounce all self-responsibility and blame others|focus completely on external factors|shut down all emotions|daydream|act out with defiance|yell and scream|threaten suicide|self-blame|act with passive-aggression|withdraw and become quiet|blame and justify|play the victim|act in a variety of compulsive ways|frantically seek reassurance|procrastinate|over-eat|binge eat|shoplift|overspend|act promiscuously|abuse substances|abuse alcohol|self-harm"]

[comment memo="Write a brief 1-2 sentence narrative about a recent specific event that highlights the patient's current difficulty in the past tense"] [textarea name="variable_6" default="when John is at work and feels overwhelmed by having too much to do, he thinks 'what's wrong with me', feels increasingly anxious and procrastinates, making the problem worse"]

[comment memo="Tick 2 boxes only: Did they complete homework? Why?"] [checkbox name="variable_60" value="completing the homework assignment|not completing the homework assignment||because it was enjoyable|because it was helpful|because of a desire to get better|because it was easy|because it made sense to do it|because it makes life feel better|because the author said so|because of someone else's urging and coercion||because there wasn't enough spare time|because of feelings of overwhelm|because of fatigue|because it didn't make sense|because of forgetting|because it was too difficult|because it feels silly"]

[comment memo="How does the Pt rate their progress since referral"] [checkbox name="variable_61" value="feeling no change|feeling a bit worse|feeling a lot worse|feeling a bit better|feeling a lot better"]

[comment memo="What is their stage of change?"] [checkbox name="variable_58" value="no awareness of the problem|pre-contemplation (is becoming aware of the problem)|is contemplating change (is aware of the problem, but struggling with ambivilence)|is preparing to change|is taking action to change|is maintaining positive changes"]

[comment memo="Describe their personality organisation?"] [checkbox name="variable_59" value="stable neurotic (can look at personal shortcomings without too much distress)|unstable neurotic (needs a lot of support to address personal shortcomings because it leads to emotional distress)|stable pre-psychotic (cannot look at personal shortcomings without splitting and polarizing)|unstable pre-psychotic (uses childish / regressive defenses to maintain stability)|stable psychotic (is deluded and unrealistic but not distressed)|unstable psychotic (feels constant anhilation anxiety and has lost touch with reality)"]

[comment memo="Choose words to describe the patient's clothing"] [checkbox name="variable_16" value="clean|dirty|unwashed|relaxed casual|smart casual|school|formal business|relaxed business|tradie-style|quirky|eccentric|disheveled|unusual"]

[comment memo="Choose one word to describe how mood appeared"] [checkbox name="variable_17" value="euthymic|anxious|angry|apathetic|ashamed|scornful|sad|irritable|defeated|depressed|flat|hypo-manic|euphoric"]

[comment memo="Choose one word to how they described their mood"] [checkbox name="variable_18" value="fine|anxious|angry|apathetic|ashamed|scornful|sad|irritable|defeated|depressed|flat|amazing|really happy"]

[comment memo="Choose one word to describe reported mood and observed affect"] [checkbox name="variable_19" value="congruent|incongruent"]

[comment memo="Choose one word to describe the patient's attitude towards you"] [checkbox name="variable_20" value="cooperative|dependent and needy|dramatic and exaggerating concerns|passive and difficult to engage|uninterested|silly and joking around|resistant|critical and verbally combative|hostile and threatening|sarcastic and taunting|irritable|fatuous|flirtatious|demanding|threatening|suspicious and guarded|defensive and resistant|manipulative|argumentative"]

[comment memo="Describe speech"] [checkbox name="variable_21" value="normal and clear|selectively mute|completely mute|loud|laconic|quiet and difficult to hear|pressured|rambling|babbling"]

[comment memo="Infer their thinking style from their speech"] [checkbox name="variable_22" value="logically congruent with mood and current circumstances|logically incongruent with mood and current circumstances|tending to take everything personally|assuming persecution by everyone|wrought with indecision and ambivalence|focused on the suspicious motives of others (persecutory thinking)|deluded and unrealistic |impaired by difficulties of reference|assuming magical ideas of influence and control|distorted by hallucinations|revealing a tendency towards pseudologica fantastica"]

[comment memo="Infer their cognitive organization from their speech"] [checkbox name="variable_23" value="was otherwise unremarkable|tended to provide too much unnecessary detail (circumstantial)|wandered between too many topics (tangential thinking)|jumped from one idea to another (loose associations)|seemed to have racing thoughts (flight of ideas)|abruptly changed topic or stopped mid-sentence (thought blocking)|tended to loop or repeat themes (obsessive)|seemed stuck on over-valued ideas (preoccupations)"]

[comment memo="Any hallucinations?"] [checkbox name="variable_24" value="no hallucinations apparent or reported|auditory hallucinations reported|visual hallucinations reported"]

[comment memo="Their level of cognitive abstraction"] [checkbox name="variable_25" value="normal and flexible|too concrete and rigid|overly abstract and needlessly conceptual"]

[comment memo="How was their grasp on reality?"] [checkbox name="variable_26" value="sound|commensurate with their age and emotional development|naive but not concerning|completely distorted and concerning"]

[comment memo="How was their insight?"] [checkbox name="variable_27" value="very self-aware|struggles with self-awareness around psychological issues|unwilling or unable to be self-aware|is in complete denial of the current psychological difficulties"]

[comment memo="How was their judgement?"] [checkbox name="variable_28" value="sound|fair|poor|dangerous and concerning"]

[comment memo="What was their suicide risk?"] [checkbox name="variable_29" value="no active suicidal ideation|vague suicidal ideation|intense suicidal ideation|having a suicide plan without serious intent|having strong intent to suicide without plan|having strong intent and a plan to suicide"]

[comment memo="What action did you take based on current suicide risk?"] [checkbox name="variable_30" value="I saw no need for further action today|I reminded the patient of their calling MHAL 1800011511 if needed, and urged them to present to the ED or call 000 in a crisis|Pt and I agreed to a harm minimization approach by removing access to lethal means|and I further discussed their risks with their parent"]

[comment memo="Choose one of the underlying belief systems:"]

[checkbox name="variable_40" value="ABANDONMENT beliefs - significant others providing support are unstable, unreliable or unpredictable.|MISTRUST beliefs - The expectation that others will intentionally hurt, abuse, cheat, or take advantage.|DEPRIVED beliefs - Feels emotionally deprived such that the expectation that one's desire for a normal degree of emotional support is never adequately met by others.|DEFECTIVENESS beliefs - The belief that one is inherently flawed, defective, and unlovable.|ALIENATION beliefs - The feeling that one is fundamentally different from other people, isolated, and not part of a community.|INCOMPETENCE beliefs - The belief that one is dependent of others to handle everyday life.|VULNERABILITY beliefs - The fear that an imminent and unpreventable catastrophe will strike at any time.|ENMESHMENT beliefs - Extensive emotional involvement and closeness with significant others at the expense of
full individuation.|INADEQUACY beliefs - Feels a deep sense of failing to achieve, will inevitably fail, or feels fundamentally inadequate relative to one's peers.|SUPERIORITY beliefs - The belief that one is superior and entitled to special rights and privileges.|SELF-CONTROL beliefs - Feels an inability or unwillingness to to exert self-control and tolerance of frustration to achieve one’s goals.|SUBJUGATION beliefs - The belief that one has to surrender control to others and to suppress one’s own needs and emotions.|SELF-SACRIFICE beliefs - An excessive focus on meeting the needs of others at the expense of one’s own needs and
well-being.|APPROVAL-SEEKING beliefs - Feels the need to constantly seek-approval with an excessive emphasis on gaining approval, recognition, or attention from other people, or fitting in, at the expense of developing a secure and true sense of self.|NEGATIVITY beliefs - Feels chronically pessimistic, which creates a pervasive, focus on the negative aspects of life - pain, death, loss, disappointment, conflict, guilt, resentment, unsolved problems, potential mistakes, betrayal, things that could go wrong, etc.|INHIBITION beliefs - The belief that one must inhibit spontaneous feelings and actions.|HIGH STANDARDS beliefs - The belief that one must strive to meet high internalized standards.|PUNITIVE beliefs - Feels the need to be excessively punitive which underscores the belief that people should be harshly punished for making mistakes."]

[comment memo="What is their current overall level of functioning out of 100?"]
[checkbox name="variable_43" value="91 – 100 No symptoms. Superior functioning in a wide range of activities|81 – 90 Absent or minimal symptoms, good functioning in all areas|71 – 80 If symptoms are present, they are transient and expected reactions to psychosocial stressors.|61 – 70 Some mild symptoms, but generally functioning pretty well.|51 – 60 Moderate difficulty in everyday functioning.|41 – 50 Serious impairment in everyday functioning.|31 – 40 Some impairment in reality testing or communication and major impairment in several areas.|21 – 30 Behaviour is considerably influenced by poor reality testing; an inability to function in almost all areas of life.|11 – 20 Some danger of hurting self or others; occasionally fails to maintain minimal personal hygiene; gross impairment in communication.|1 – 10 Persistent danger of severely hurting self or others; persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death.|0 Inadequate information"].

[comment memo="What is the therapy goal?"] [checkbox name="variable_44" value="enhance mood|reduce psychotic Sx with medication|learn relaxation skills|learn mindfulness and meta-cognition skills|develop greater insight|decrease eating|increase eating|decrease ETOH|endure withdrawal of substances|enhance distress tolerance skills|boost hope|reduce symptom severity|improve sleep|enhance a sense of self-efficacy|reduce pain|increase knowledge|increase assertiveness|motivate medical treatment|enhance problem-solving|increase resilience|address distorted cognitions and beliefs|treat medical concerns|improve medication adherence and compliance|enhance self-agency|strengthen ego functioning"]

[comment memo="What is the rate of progress?"] [checkbox name="variable_45 value="excellent|good|fair|poor|negligible"]

[comment memo="What factors are impacting on recovery?"] [checkbox name="variable_46" value="is highly motivated to change|lacks a strong education background|experiences significant work stress|has housing problems|has an over-burdening debt|experiences economic disadvantage|is not very psychologically minded|lack meta-cognitions|has very poor insight|lives in a difficult social environment|has financial stress|over-identifies with sick role|has ongoing legal problems|has background of childhood adversity|has history of victimization|is unemployed|has problems related to upbringing|has chronic medical problems|is pregnant|is very religious|has discord with family|has discord with most people|has extreme beliefs|has personality instability|has significant lifecycle transition difficulties|has substance misuse concerns|has low self-efficacy|has sexual difficulties|has medication adherence and compliance problems|has rigid psychological defenses|has relationship problems|has feelings of hopelessness|is unaware of problem|is denying of the problem|has secondary gains from the sick role|has no motivation to change"]

[comment memo="Tick one to describe the degree to which progress is impacted (by the above):"] [checkbox name="variable_57" value="which does not particularly impact on|which mildly impacts on|which greatly impacts on|which completely negates"]

[comment memo="Choose one of therapeutic modality"]

[checkbox name="variable_47" value="Cognitive Behavioural Therapy|Dialectical Behaviour Therapy|Behaviour Therapy|Relaxation Training|Mindfulness Training|Narrative Therapy|Family-based therapy|Group Therapy|Skills training|Psychoeducation|Insight oriented counselling|Emotional regulation skills training|Psychodynamic Counselling Techniques|enhance Psychosocial supports"]

[comment memo="add a specific technique if you want, using the format provided"] [textarea name="variable_7" default="in particular, I used guided meditation"].

[comment memo="Choose a possible diagnostic area:"]

[checkbox name="variable_48" value="Developmental Disorder|Schizophrenia Spectrum Disorder|Bipolar Disorder|Depressive Disorder|Anxiety Disorder|OCD|Trauma and Stress related Disorder|Dissociative Disorder|Somatic Symptom related|Feeding and Eating related|Elimination related|Sleep-Wake Disorder|Sexual Dysfunction|Gender Dysphoria|Impulse Control related disorder|Substance related disorder|Neurocognitive Disorder|Personality disorder"]

[checkbox name="variable_49" value="but would not meet criteria for a diagnosis at this time|and meets criteria for a clinical diagnosis"]

Copy and paste everything below this line into NOTEPAD, then after editing it, paste it into your Pt records

[text name="variable_1" default=""] reported [checkbox name="variable_60" value=""].

Overall, [checkbox name="variable_1" value=""] reports [checkbox name="variable_61" value=""] since [checkbox name="variable_2" value=""] referral.


Today, [text name="variable_1" default=""] raised concerns regarding: [checkbox name="acaperf" value=""] [checkbox name="sofac" value=""] [checkbox name="conduct" value=""] [checkbox name="cogfac" value=""] [checkbox name="motdif" value=""] [checkbox name="becon" value=""] [checkbox name="afcon" value=""] [checkbox name="Seles" value=""] [checkbox name="Relcon" value=""] [checkbox name="Lifetran" value=""] [checkbox name="Physcom" value=""] [checkbox name="Subab" value=""] [checkbox name="Selman" value=""] [checkbox name="Trau" value=""] [checkbox name="Psychst" value=""] [checkbox name="Ach" value=""] [checkbox name="Indef" value=""] [checkbox name="Qual" value=""].


[textarea name="variable_6" default="when John was at work last week and felt overwhelmed by having too much to do, he thought 'what's wrong with me', felt increasingly anxious and noticed he procrastinated, making his overwhelm feel worse"]


-- Appearance & Mood --

[text name="variable_1" default=""] presented wearing [checkbox name="variable_16" value=""] clothes. [checkbox name="variable_1" value=""] looked visibly [checkbox name="variable_17"] and reported [checkbox name="variable_2" value=""] mood as [checkbox name="variable_18" value=""] which seemed [checkbox name="variable_19" value=""]. [checkbox name="variable_2" value=""] overall attitude towards me was [checkbox name="variable_20" value=""]. Personality features: [checkbox name="variable_52" value=""].

-- Thinking & Judgement --

[text name="variable_1" default=""]'s speech was [checkbox name="variable_21" value=""]. Based on the content of [checkbox name="variable_2" value=""] speech I inferred [checkbox name="variable_2" value=""] thinking as [checkbox name="variable_22" value=""]. I further noted [checkbox name="variable_2" value=""] thinking [checkbox name="variable_23" value=""].

There were [checkbox name="variable_24" value=""]. Overall I found [text name="variable_1" default=""]'s thinking to be [checkbox name="variable_25" value=""] and [checkbox name="variable_2" value=""] grasp on the reality of [checkbox name="variable_2" value=""] circumstances to be [checkbox name="variable_26" value=""]. On talking with [text name="variable_1" default=""] I determined [checkbox name="variable_1" value=""] [checkbox name="variable_27" value=""]. Based on recent behaviour and thinking I determined [checkbox name="variable_2" value=""] judgement to be [checkbox name="variable_28" value=""].

-- Suicide Risk --

When I asked [checkbox name="variable_3" value=""] about suicidal thinking, [checkbox name="variable_1" value=""] reported [checkbox name="variable_29" value=""]. Based on this [checkbox name="variable_30" value=""].


[checkbox name="variable_47" value=""], [textarea name="variable_7" default=""].


Global rating out of 100: [checkbox name="variable_43" value=""]

Known triggers: [checkbox name="variable_53" value=""]

Perpetuating thoughts: '[checkbox name="variable_54" value=""]'

Cognitive distortions: [checkbox name="variable_51" value=""]

Unhelpful coping behaviours: [checkbox name="variable_55" value=""]

Situation this problem is most likely to occur: [checkbox name="variable_50" value=""] [textarea name="variable_8" default=""]

Pathogenic beliefs: [checkbox name="variable_40" value=""]

Diagnostic features: [checkbox name="variable_48" value=""], [checkbox name="variable_49" value=""]

Factors impacting on recovery: [checkbox name="variable_46" value=""]

Stage of change: [checkbox name="variable_58" value=""]

Personality organization: [checkbox name="variable_59" value=""]


Therapeutic goals: [checkbox name="variable_44" value=""]

I will address [text name="variable_1" default=""]'s presenting concerns with [checkbox name="variable_47" value=""].
Patients first name

he or she

his or her

him or her

Tick as many boxes to describe what you worked on today:



















What situation is this feeling at its worst? Choose one describe the situation or name the specific person if needed

What cognitive distortions are apparent? Choose one

Were there any obvious personality features in the transference? Choose one

What usually triggers the patient's concern - choose one

Choose the patient's unhelpful thought that is triggered. Choose only one

Check one maladaptive coping behaviour

Write a brief 1-2 sentence narrative about a recent specific event that highlights the patient's current difficulty in the past tense

Tick 2 boxes only: Did they complete homework? Why?

How does the Pt rate their progress since referral

What is their stage of change?

Describe their personality organisation?

Choose words to describe the patient's clothing

Choose one word to describe how mood appeared

Choose one word to how they described their mood

Choose one word to describe reported mood and observed affect

Choose one word to describe the patient's attitude towards you

Describe speech

Infer their thinking style from their speech

Infer their cognitive organization from their speech

Any hallucinations?

Their level of cognitive abstraction

How was their grasp on reality?

How was their insight?

How was their judgement?

What was their suicide risk?

What action did you take based on current suicide risk?

Choose one of the underlying belief systems:

What is their current overall level of functioning out of 100?

What is the therapy goal?

What is the rate of progress?

What factors are impacting on recovery?

Tick one to describe the degree to which progress is impacted (by the above):

Choose one of therapeutic modality

add a specific technique if you want, using the format provided.

Choose a possible diagnostic area:

Copy and paste everything below this line into NOTEPAD, then after editing it, paste it into your Pt records

reported .

Overall, reports since referral.


Today, raised concerns regarding: .



-- Appearance & Mood --

presented wearing clothes. looked visibly and reported mood as which seemed . overall attitude towards me was . Personality features: .

-- Thinking & Judgement --

's speech was . Based on the content of speech I inferred thinking as . I further noted thinking .

There were . Overall I found 's thinking to be and grasp on the reality of circumstances to be . On talking with I determined . Based on recent behaviour and thinking I determined judgement to be .

-- Suicide Risk --

When I asked about suicidal thinking, reported . Based on this .




Global rating out of 100:

Known triggers:

Perpetuating thoughts: ' '

Cognitive distortions:

Unhelpful coping behaviours:

Situation this problem is most likely to occur:

Pathogenic beliefs:

Diagnostic features: ,

Factors impacting on recovery:

Stage of change:

Personality organization:


Therapeutic goals:

I will address 's presenting concerns with .

Result - Copy and paste this output:
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