MH – Youth Progress Note

SUBJECTIVE REPORT

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OBSERVATIONS

Appearance: [checkbox value="no concerns, appropriately dressed, relaxed|seemed physically under-developed|visibly overweight|visibly underweight|inappropriately clothed|disheveled clothing|bizarre clothing|neglected grooming|tense posture|slumped posture|bizarre mannerisms|slowed movement|repetitive movements|restless|agitated|tremors"]

Attention: [checkbox value="no concerns, attended well for the duration of our session|inattentive|distractible|hyper-vigilant|scattered concentration|seemed preoccupied|was confused|focused on irrelevancies|poorly able to access memories|confabulated"]

Engagement: [checkbox value="no concerns, engaged well|avoided eye contact|fixed staring|glared at author|dependent and needy|dramatic and theatrical|passive and difficult to engage|inaccessible|asserted 'I dont know' to most questions|didn't seem interested in treatment|seemed unmotivated to change|was silly and joking around|was acting out|defered to parent throughout session|critical and verbally combative|sarcastic and taunting|irritable|fatuous|flirtatious|demanding|threatening|suspicious and guarded|defensive and resistant|argumentative|hauty and superior towards author"]

Affect: [checkbox value="no concerns, expressive and emotionally regulated|struggled to control emotions|emotionally shut down|diminished emotional expression|lacking emotional expression|was anxious and seemed worried|angry and irritable|apathetic|ashamed|prideful|sad|hostile mood|pessimistic|depressed|gloomy|too upbeat|euphoric"]

Speech and thoughts: [checkbox value="spoke clearly and comprehensively|was selectively mute|was completely mute|loud|laconic|quiet and difficult to hear|pressured|rambling|babbling|incongruent with mood and current circumstances|took everything personally|struggled to make logical links between behaviours and consequences of those behaviours|wrought with indecision and ambivalence|suspicious about the motives of others (persecutory thinking)|deluded and unrealistic|impaired by difficulties of reference|assumed magical ideas of influence and control|distorted by hallucinations|revealed a tendency towards pseudologica fantastica|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)"]

Orientation: [checkbox value="no concerns|AH|VH|poor judgement|distorted reality testing|poor insight|complete denial|unaware of time|unaware of place|unaware of self"]

Stressors disclosed without prompting: [checkbox value="nil|money|school|sex|substances|self-esteem|education|housing|employment|mood|family|work|grief and loss|illness|transitions|legal difficulties|peer group|relationship"]

Suicide risk: [select value="denied active suicidal ideation when asked|vague suicidal ideation|intense suicidal ideation|has a suicide plan without strong intent|has strong intent to suicide without a plan|has strong intent and a plan to complete suicide"].

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ASSESSMENT

Risk assessment: [checkbox name="variable_30" value="I saw no need for further action today|I reminded the patient and parents of their calling MHAL 1800011511 if needed, and urged them to present to the ED or call 000 in a crisis|recommended using after-hours support lines such as KIDS HELPLINE, LIFELINE, or eHEADSPACE|Pt and I agreed to a harm minimization approach by removing access to lethal means|I further discussed their risks with their parent|agreed with parent to remove self-harm means|I called emergency services and reported my concerns|I called the MHAL and reported my concerns|I made a notification of suspected abuse to FACS"]

Diagnostic features: [checkbox name="variable_48" value="Developmental Disorder|Schizophrenia Spectrum Disorder|Bipolar Disorder|Depressive Disorder|Anxiety Disorder|OCD|Trauma, Stress and Adjustment related Disorders|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|emerging 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"].

Pathogenic beliefs: [checkbox value="Nothing of note|ABANDONMENT (clingy) - others will leave me.|MISTRUST (paranoid-suspicious) - others will intentionally hurt me.|DEPRIVED (craving and FOMO) - I'm constantly missing out.|DEFECTIVENESS (low self worth) - I'm inherently flawed and unlovable.|ALIENATION (isolative) - I'm fundamentally different|VULNERABILITY (anxious) - an imminent and unpreventable catastrophe will strike at any time.|ENMESHMENT (co-dependent) - emotional involvement with others is preferred over individuation.|SUPERIORITY (grandiose) - one is superior and entitled to special privileges.|SELF-CONTROL (chaotic) - unable or unwilling to tolerate frustration to achieve one’s goals.|SELF-SACRIFICE (masochistic) - ignore one’s own needs.|NEGATIVITY (pessimistic) - life never works out.|INHIBITION (emotionally suppressed) - one must inhibit spontaneous feelings and actions.|HIGH STANDARDS (perfectionsism) - strives to meet high internalized standards.|PUNITIVE (sadistic) - people should be harshly punished for making mistakes."]

Overall functioning rated 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 Unable to rate"].

Maladaptive coping: [checkbox name="variable_55" value="Nothing of note|restrict calories|becomes over-assertive|feels the need to over-perform|avoids the situation|negatively ruminates|mentally replays unpleasant events|over-exercises|immerse in fantasy|negative self-talk|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"]

Cognitive distortions: [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)"].

My impressions of family functioning impacting on child: [checkbox value="nothing of note|struggle to problem solve together|children have too much control|parentification of the children noted|ineffective communication|unaware of their emotional needs|the parents seem emotionally unresponsive|high expressed emotion|parents struggle to set limits|struggles for control|parents are unwilling or unable to assist their child with refeeding|low warmth|parental conflict|parents are prioritizing their needs|general functioning is poor|a lack of assigned roles|splitting behaviours noted|parents are time poor|parents misuse substances|parents MH issues|parents struggle with finances|family is too big for parents to effectively manage"]

Medications: [checkbox value="N/A|nil concerns, working as intended|complaining of side effects|asserts dose is too high|asserts dose is too low|wants to change meds|wants to discuss meds with Dr"]

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Progress: [checkbox name="variable_45 value="excellent|good|fair|poor|negligible"]

THERAPEUTIC APPROACH

Therapeutic Goals: [checkbox value="learn relaxation skills|learn meta-cognitive detachment|developing greater insight|decreasing over-eating behaviours|increasing eating and calorie intake|decreasing ETOH misuse|enduring withdrawal of substances|enhancing distress tolerance skills|feeling more hopeful about the future|improving sleep|enhancing a sense of self-efficacy|reducing physical pain|increasing psychological knowledge|becoming more assertive|adhering to recommended medical treatment|enhancing problem-solving skills|increasing resilience|modifying distorted cognitions and beliefs|becoming motivated to treat medical concerns|improving medication adherence and compliance|feeling enhanced self-agency|strengthening-ego functioning|Symptom relief|Improve insight|Enhance agency|Consolidate identity|Enhance self-esteem|Recognizing and handling feelings|Improve reality-testing (handling life as it is)|Improve love relationships|Improve work relationships|Encourage play|improve mature dependency|improve assertiveness|Reduce envy|Self-acceptance|Encourage problem-solving|Find serenity|Enhance pleasure"].

Therapy style: [checkbox name="variable_47" value="Supportive counselling|Increasing external supports|Cognitive Behavioural Therapy|- challenging dysfunctional cognitions|Dialectical Behaviour Therapy|- Mindfulness skills|- Emotional regulation|- Distress tolerance|Behaviour Therapy|Relaxation 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, using the format provided"] [textarea name="variable_7" default=""]

Patient [select value="engaged well.|struggled to engage.|was unable or unwilling to engage today."]

PLAN

Focus of next session: [textarea default=""]

Homework: [checkbox value="none|create a SUDS hierarchy|exposure to feared stimulus|relaxation practice|practice cognitive distancing|reflect on content of session|practice skills form today|notice patterns of dysfunction as they arise|keep a diary of emotions|keep a food diary of meals and feelings"]. [textarea default=""]

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