Prog Notes v4.1

[comment memo="|"][checkbox name="init" memo="Initial Session |" value=""][comment memo="Motivational Interviewing" memo_size="large" memo_color="blue"][checkbox name="MI" value=""] [comment memo=" | Play Therapy" memo_size="large" memo_color="pink"][checkbox name="play" value=""] [comment memo=" | TBRI" memo_size="large" memo_color="powderblue"][checkbox name="tbri" value=""] [comment memo=" | EMDR" memo_size="large" memo_color="purple"][checkbox name="emdr" value=""] 

[select name="colum" memo="C-SSRS | " value="no|none|low|moderate|high"][link url="https://www.soapnote.org/mental-health/gen-prog-notes-stuff-wip/" memo="General Interventions | "][link url="https://www.soapnote.org/mental-health/star/" memo="Initial w/ C-SSRS | "][link url="https://www.soapnote.org/mental-health/star-correspondence-wip/" memo="Correspondences"]

Counselor met with [select name="yf" value="Youth|Family|PCG"] for [select name="virt" memo="Session | " value="in-person|phone|telehealth"] [select name="sessiontype" value="individual|family|caregiver|intake|consultation"] session. [conditional field="virt" condition="(virt).is('phone')||(virt).is('telehealth')"]Counselor confirmed location as [text name="virtloc" default="Waco, Texas, at home"]. Counselor confirmed own identity and location. [/conditional]
[conditional field="init" condition="(init).is('')"] Family completed all required paperwork and discussed confidentiality. Counselor discussed and explained client rights, service limitations, professional credentials, supervision, and paperwork requirements. Family discussed the reasons they sought services and the presenting problem being [textarea name="presprob" default="struggles with emotional regulation/sh/si/anxiety/angry outburts\ncoping skills, overall family functioning etc."]
Counselor and family discussed strategies they can begin trying to help youth get on the right track.[/conditional]
[conditional field="init" condition="(init).isNot('')"][textarea name="variable_1" default="Today’s appointment focused on "][/conditional][conditional field="MI" condition="(MI).is('')"]
[comment memo="Motivational Interviewing - General Session" memo_color="blue"  memo_size="large"]
Counselor assessed discrepancies and [var name="yf"] seems to be in [select name="MI_stage" value="precontemplation|contemplation|determination|action|maintenance"][conditional field="MI_stage" condition="(MI_stage).is('precontemplation')"] stage and [checkbox name="pre1" value="worked to increase their awareness and build commitment to change|they reported their readiness ruler to be at # and explored strengths, supports and values to create solutions."] [/conditional][conditional field="MI_stage" condition="(MI_stage).is('contemplation')"]stage and helped [var name="yf"] explore reasons to change and strengthen level of self-efficacy. [checkbox name="variable_1" value="They processed the benefits and costs of choice to be made."][/conditional][conditional field="MI_stage" condition="(MI_stage).is('determination')"]stage and worked with [var name="yf"] to identify and determine the best course of action to take in seeking the desired change. [/conditional][conditional field="MI_stage" condition="(MI_stage).is('action')"]stage and collaborated with [var name="yf"] to identify next step of action needed to achieve goal. [/conditional][conditional field="MI_stage" condition="(MI_stage).is('maintenance')"]stage and helped [var name="yf"] identify useful strategies to continue success in goal areas and prevent relapse.[/conditional]
[/conditional][conditional field="play" condition="(play).is('')"]
[comment memo="Play Therapy - General Session"  memo_size="large" memo_color="pink"]Counselor utilized [checkbox name="playmedium" value="non-directive play|sand tray|art|puppets|clay|miniatures|storytelling|expressive arts"] intervention from [select name="playtheory" value="Child-Centered Play Therapy|Theraplay, Adlerian Play Therapy|Child Parent Relational Therapy|Gestalt Play Therapy|Filial therapy|family play therapy"] [textarea name="variable_1" default="to improve/increase/bring awareness to emotions/regulation/healthy expression of emotion"][comment memo="Limit-setting?" memo_color="pink"][checkbox name="lim" value=""][conditional field="lim" condition="(lim).is('')"]Counselor used limit setting to protect the [checkbox name="variable_1" value="child|therapist|toys|room"] to provide [select name="variable_1" value="structure|reality testing"]. During play youth [select name="limittest1" value="did|did not"] test limits.[conditional field="limittest1" condition="(limittest1).is('did')"] Limit testing by youth was [select name="limittest2" value="none|low|medium|high"].[/conditional][/conditional] Counselor observed youth utilizing [text name="toytype" default=" "]toys and child engaged in play[textarea name="playtheme" default="with themes of exploratoration, relationships, power /control, helplessness/inadequate, safety/security/mastery, nurturing, death/loss/grieving/, sexualized and other)\n dynamics of play: messy, chaotic, disorganized, destructive, constructive, neat, orderly, frenetic"].[comment memo="Quotes from child" memo_color="pink"][checkbox name="quotes" value=""][conditional field="quotes" condition="(quotes).is('')"] During play youth verbalized [textarea name="ysaid" default=""][/conditional][comment memo="Who youth in/excluded in play" memo_color="pink"][checkbox name="players" value=""][conditional field="players" condition="(players).is('')"]Youth [select name="yplayincl" value="included|excluded"] [select name="yplaywho" value="therapist|parent|PCG|SCG|CGs"] in the play.[/conditional]
[/conditional][conditional field="tbri" condition="(tbri).is('')"][comment memo="Trust Based Relational Intervention" memo_color="powderblue" memo_size="large"][comment memo=" | Connecting" memo_color="powderblue"][checkbox name="tbri2" value=""][comment memo=" | Empowering" memo_color="powderblue"][checkbox name="tbri1" value=""][comment memo=" | Correcting" memo_color="powderblue"][checkbox name="tbri3" value=""][conditional field="tbri2" condition="(tbri2).is('')"]. Counselor provided psychoeducation focused on the TBRI Connecting Principle. Counselor discussed [checkbox name="tbri2_1" value="implementation of engagement strategies that can help promote connection (behavioral matching, nurturing touch, warm eyes, voice quality, playful engagement)|the attachment cycle and how healthy attachment is the foundation for trust, self-worth, self-efficacy, self-regulation, and mental health|the importance of meeting a child’s needs and how that may help facilitate secure attachment|the effect trauma can have on attachment|the positive effects of safe, healthy touch and how the family can implement touch into their daily lives"]. [checkbox name="tbri2_2" value="Family completed a Nurture Group and practiced giving care, receiving care, negotiating their needs, and having an autonomous self."][/conditional][conditional field="tbri1" condition="(tbri1).is('')"]Counselor provided psychoeducation focused on the TBRI Empowering Principle. Counselor discussed [checkbox name="tbri1_1" value="the importance of youth being fully hydrated at all times|fluctuations in blood sugar levels and how they may affect youth’s mood, memory, anxiety level, and ability to concentrate|giving youth a meal or snack every two hours to help decrease the intensity of youth’s blood sugar fluctuations|the function of sensory input|different types of sensory input (vestibular, proprioceptive, and tactile)|sensory defensive and sensory seeking behaviors and what those may look like at home/school/etc.|youth completing a sensory activity every two hours|the difference between physical safety and felt safety|fight, flight, or freeze and what that may look like behaviorally|using transitional notecards and/or transitional warnings|the development of self-regulation (other regulation, co-regulation, and self-regulation)|using an engine plate to help youth gain awareness and be able to effectively communicate their level of regulation"]. [textarea name="tbri1_2" default="Counselor introduced the TBRI problem solving worksheet to help the family notice patterns and problem solve youth’s behaviors.\nthe regulation strategy (magic mustache, bowl of soup, wall pushes, sitting push-ups, chewing gum, blowing bubbles, etc.…)"][checkbox name="tbri1_3" value="Counselor provided family with a handout listing examples of sensory rich activities|Counselor and family processed about what may help youth feel safe."][/conditional][conditional field="tbri3" condition="(tbri3).is('')"]Counselor provided psychoeducation focused on the TBRI Correcting Principle. Counselor discussed [checkbox name="tbri3_1" value="the goals of correction (connection, contentedness, and changed behavior)|balancing nurture and structure when parenting|implementing new correcting strategies proactively when youth is calm, alert, and has his/her basic needs met|the implementation of choices and what that may look like for the family|teaching youth how to negotiate their needs and that their words have power by using compromises|setting the bar appropriately so that youth is challenged and also able to be successful|being mindful of youth’s developmental age and how that may differ from their chronological age due to trauma|examples of appropriate choices and modeled how to give youth a choice using the appropriate tone, cadence, and volume|the TBRI Life Value Terms and how the family could use these terms to have a consistent language defining expectations|the TBRI IDEAL Response and discussed how the family may utilize this response|the TBRI Levels of Response™ and discussed how the family may implement this set of strategies for redirecting behaviors"].[/conditional]
[/conditional][conditional field="emdr" condition="(emdr).is('')"]
[comment memo="Phase 1 (History And Treatment Planning)" memo_color="purple"][checkbox name="p1" value=""][conditional field="p1" condition="(p1).is('')"][comment memo="Build rapport, get history, discuss goals, screen for dissociation" memo_color="plum"]
Counselor provided family/youth with psychoeducation on [textarea name="emdr1" rows="1" default="trauma response, anxiety, affect phobia, disassociation, impact of trauma on the brain, and EMDR"]. Counselor and [var name="yf"] identified goals for treatment.[checkbox name="emdr1.1" value="Counselor discussed Eye Movement Desensitization and Reprocessing (EMDR) as treatment option with family/youth. Counselor provided family with psychoeducation on EMDR. Family agreed to proceeding with EMDR therapy."]
[checkbox name="emdr1.2" value="Counselor assessed for dissociative experiences|Youth identified the first occurrence, worst occurrence, and most recent occurrence of presenting problem|Counselor and Youth/Family created a timeline to assess for potential target memory/feeling."][/conditional]
[comment memo="Phase 2 (Preparation)" memo_color="purple"][checkbox name="p2" value=""][conditional field="p2" condition="(p2).is('')"][comment memo="How EMDR works, what to expect, relaxation, Safe place, container" memo_color="plum"]
[checkbox name="emdr2.1" value="Counselor discussed and demonstrated all available options of bilateral stimulation|Counselor educated Youth on Safe Place Protocol and the importance of exploring resources with the family and/or youth|Youth described/created a safe place using the protocol|Youth practiced Safe/Comfortable Place on mildly disturbing event|Counselor discussed and demonstrated stabilization interventions|Youth practiced stabilization interventions"]. Youth identified [text name="emdr2.2" default=""] as a resource.[/conditional]
[comment memo="Phase 3 (Assessment)" memo_color="purple"][checkbox name="p3" value=""][conditional field="p3" condition="(p3).is('')"][comment memo="Find target, get info to grab VOC and SUDs" memo_color="plum"]
[checkbox name="emdr3" value="Counselor assessed for target|positive and negative cognitions were discussed"].Youth identified triggers/stressors that elicit [textarea name="emdr3_1" rows="1" fillable="true" default="feelings of ***sadness*** in ***body***"].[textarea name="emdr3_2" rows="1" fillable="true" default="Youth rated SUDs at ****** and VOC at ******"][/conditional]
[comment memo="General Session" memo_color="purple"][checkbox name="p4" value=""][conditional field="p4" condition="(p4).is('')"]Counselor and youth are working in Phase [select name="phase" value=" |1 (History And Treatment Planning)|2 (Preparation)|3 (Assessment)|4 (Desensitization)|5 (Installation)|6 (Body Scan)|7 (Closure)|8 (Reevaluation)"]. Counselor utilized [checkbox name="emdr4" value="resourcing|safe place|cognitive interweaves|sand tray|Future Template|resource development and installation|positive cognitions and installation|Container exercise (Affect Regulation)|Spiral Technique|Recent Event Protocol|Float Back Exercise"] to facilitate processing as needed. Counselor utilized [select name="emdr5" value="eye movements|tapping|auditory|tappers (buzzies)"] as the primary form of bilateral stimulation during session. In assessing progress, [textarea name="emdr6" rows="3" fillable="true" default="Youth rated SUD went from ***#*** to ***#*** and VOC went from ***#*** to ***#***."][checkbox name="emdr7" value="Counselor and youth were unable to complete session and utilized container to close out session"][/conditional][/conditional]
[conditional field="colum" condition="(colum).isNot('no')"] Assessed client using the C-SSRS.[/conditional][conditional field="colum" condition="(colum).is('none')"] Youth did not meet criteria.[/conditional][conditional field="colum" condition="(colum).is('low')||(colum).is('moderate')||(colum).is('high')"]Youth met criteria for [var name="colum"] risk ([select name="intent" value="without|with"] intent, [select name="plan" value="without|with"] plan).[/conditional][conditional field="colum" condition="(colum).is('high')"][comment memo_color="red" memo="Here is information specific to protocol with high risk."]Counselor discussed results with PCG directly and the need for youth to [textarea name="variable_1" default="receive psychiatric evaluation at the nearest hospital\nCall MCOT/MOT for psychiatric evaluation."]Counselor discussed results with PCG directly. A safety plan was constructed, including removing access to means and  PCG's responsibilities for youth's safety. Appropriate hospital/MCOT/MOT information was provided. Counselor spoke with PCG about attaining an ROI for [text name="variable_1" default="hospital/MCOT/MOT"] and a follow up [text name="variable_1" default="today/the next day"] to confirm youth received discussed services and discuss outcome of the evaluation. Based upon the evaluation outcome, counselor discussed offering next appointment as needed.[/conditional][conditional field="colum" condition="(colum).is('moderate')"][comment memo_color="orange" memo="Here is information specific to protocol with moderate risk."]Counselor discussed results with PCG directly. A safety plan was constructed, including removing access to means and  PCG's responsibilities for youth's safety. Appropriate hospital/MCOT/MOT information was provided. Next appointment is scheduled within 3 days.[/conditional][conditional field="colum" condition="(colum).is('low')"][comment memo_color="yellow" memo="Here is information specific to low risk."]Counselor discussed results with PCG directly. A safety plan was constructed, including removing access to means and  PCG's responsibilities for youth's safety. Appropriate hospital/MCOT/MOT information was provided.Next appointment is scheduled within 10 days.
[/conditional][comment memo="Affect range" memo_color="blue" memo_size="large"]
[select name="aff_0" value="Youth|PCG|Family"] appeared [checkbox name="aff_1" value="engaged|disengaged|content|depressed|tired|anxious|interactive|withdrawn|calm|agitated|cooperative|guarded|defensive|hostile"] as evidenced by [checkbox name="aff_2" value="self-report|minimal participation in discussion|maximal participation in discussion"][select name="aff_3" value=",||:"][comment memo="Speech" memo_color="blue"][checkbox name="aff_4" value=""][conditional field="aff_4" condition="(aff_4).is('')"]speech that was [checkbox name="aff_4a"  value="normal|atypically slow|atypically fast|loud|soft|monotone|impaired|unintelligible|warm in tone|flat-toned|relaxed|hesitant|hyperverbose|unable to be assessed because client was non-responsive"]; [/conditional][comment memo="Behavior/Non-verbals" memo_color="blue"][checkbox name="aff_5" value=""][conditional field="aff_5" condition="(aff_5).is('')"][checkbox name="aff_5a" value="fidgeting|jittery movements|good eye contact|fair eye contact|poor eye contact"]; [/conditional][comment memo="Affect range" memo_color="blue"][checkbox name="aff_6" value=""][conditional field="aff_6" condition="(aff_6).is('')"]a [select name="aff_6a" value="broad and reactive|constricted|blunted|flat|dysregulated|inappropriate"] range of affect; [/conditional] [comment memo="Thought form/content" memo_color="blue"][checkbox name="aff_7" value=""][conditional field="aff_7" condition="(aff_7).is('')"]thought form/content that was[checkbox name="aff_7a" value="normal|future-oriented|logical, linear and goal-oriented|past oriented and somber|goal directed|scattered|hopeful|remorseful|enthusiastic|resigned|oriented and normal|disorganized|tangential|preoccupied and/or obsessive|characterized by paucity of ideas|with displayed instances of thought blocking|circumstantial"] [/conditional][comment memo="Focus" memo_color="blue"][checkbox name="aff_8" value=""][conditional field="aff_8" condition="(aff_8).is('')"] [select name="aff_8a" value="developmentally appropriate|limited|impaired|severely impaired"] focus[/conditional]
[comment memo="Action Plan" memo_color="blue" memo_size="large"]
Action Plan: [select name="APwho" value="Family|Youth|PCG"] discussed progress towards goals set on action plan and [select name="variable_5" value=" reported goals are still appropriate and progress is being made|updated action plan to reflect continued progress toward long-term goals|reported goals have been met and action plan will be updated at next session|reported goals have been met and family updated action plan today|Counselor collaborative with family and developed initial goals and tasks for the action plan. Action plan was completed and signed and a copy was given to the family|Counselor collaborative with family and developed initial goals and tasks for the action plan. Action plan was completed and sent to the family via EHR portal for signatures|Action plan was not discussed during this session."]
| Initial Session |Motivational Interviewing | Play Therapy | TBRI | EMDR

C-SSRS | General Interventions | Initial w/ C-SSRS | Correspondences

Counselor met with for Session | session.


Affect range
appeared as evidenced by Speech Behavior/Non-verbals Affect range Thought form/content Focus
Action Plan
Action Plan: discussed progress towards goals set on action plan and

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Sandbox Metrics: Structured Data Index 0.79, 152 form elements, 35 boilerplate words, 5 text boxes, 11 text areas, 40 checkboxes, 21 drop downs, 3 links, 7 variables, 31 comments, 34 conditionals, 180 total clicks
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