Mst copy

Chief complaint:[text name="variable_Chief complaint" default="sample text"]Gender:[checkbox name="variable_gender" value="Male|Female|Other"]
The client's preferred pronouns:[checkbox name="Pronoun" value="He|Him|She|her|they|them|other:"][text name="pronoun other" default="sample text"]Pharmacy:[text name="variable_Pharm" default="sample text"]Allergies:[checklist name="Allergies" value="KNDA|NKA|Allergy:"]Reaction:[text name="Reaction" default="sample text"]HPI
[text name="Name" default="name"]is a [text name="age" default="age, gender, ethnicity,"]seeking treatment for[text name="reason" default="reason they are here"]that started[text name="started" default="started"]and has[select name="variable_Cont1" value="been continous|intermitant"]
The intensity of the symptoms is a [text name="N" default="number"]on a scale of 0 to 10 with 10 being the most intense and zero being the least intense.
Assocating factors:[text name="variable_C" default="correlating"]
Modifing factors:[text name="variable_bw" default="BetterWorse"]The clients mood has been[text name="variable_Mood" default="mood"]over the past two weeks.They report[text name="variable_interest" default="interest"]They described their appitite as:[checkbox name="variable_app" value="high|low|increased|decreased|stayed about the same"]They have [select name="variable_gained" value="gained|lost"] weight. They[select name="variable_qasw" value="endorsed|denied"] binging, restrcting, or purging meals.They describe their sleep as [text name="variable_sleepss" default="good/bad/better"]
They report they are able to fall and stay asleep.
They denied waking up earlier than they have to.
They[text name="variable_dee" default="Endorse/Describe"]nightmaresTheir energy level has been a [text name="variable_nbss" default="number"]on a scale of 0 to 10 with ten being the hightest energy level and zero being the lowest.They [text name="variable_1saf" default="agreed/described"] energy that does not last throgh the day.They noticing that theri movements really slow down.
They [text name="variable_1as" default="End/den/descri"] feeling restless, pacing, and ubale to sit down for long.The client [text name="variable_1dsfa" default="described"feelings of hoplessness and worthlessness
The client [text name="variable_1dsfdc" default="described"]feelings of pervasive, irrational guilt
The client [text name="variable_1dsfcvf" default="described"]negative feelings towards themself and feelings of inadaquecy
The client [text name="variable_1dagh" default="described"]The client [text name="variable_1daazgh" default="described"]that they are unable to maintain concetration are are easily distracted
The client [text name="variable_1ddsdfagh" default="described"]that hey are unable to read materal with good comprehension because of being seasily disctracted
The client [text name="variable_1dafhjklgh" default="described"]The client [text name="variable_1dsfa" default="denied"]SI, HI, and, psychosis.
The client [text name="variable_1asdf" default="expressed"] that they are experiencing SIbut have not taken any actionson these thoughts.
The client [text name="variable_1saf"ccv default="reported"]SI thoughts have resulted in suicidal gestures.
The client [text name="variable_1gbyyy" default="denied"]any suicidal thoughts or gestures.
The client [text name="variable_1dsfafs" default="denied"]hallucinations or delusions indicating that the depression has a psychotic component.
the client[text name="variable_suicide1" default="reported"] recurrent thoughts of their own death.
the client[text name="variable_suicide11" default="reported"]experiencing recurrent SI, but denied having any specific plan to implement suicidal urges.
the client[text name="variable_suicide12" default="reported"]experiencing ongoing SI and has developed a specific plan for SI.
Althoughthe client[text name="variable_suicide13" default="acknoledged"] that they have developed a suicide plan, they indicated that the urge is controllable and promised not to implement such a plan.
the client[text name="variable_suicide14" default="has"]mad a suicide attempt within the past [text name="variable_1rrre" default="week"]the client[text name="variable_1azx" default="exhibits"]an abnormally and persistently elevated, expansive, or irritable mood.
the client[text name="variable_1xcvxb" default="functioning"]has been affected by their mania.
the client[text name="variable_1kjhgfe5" default="gave"]evidence of pressured speech within the session.
the client[text name="variable_111" default="demonstarted"] an inability to stay focused on one subject and moved quickly from one topic to another.
the client[text name="variable_122" default="gave evidence"] of grandiose ideas regarding their abilities, plans, and accomplishments
the client[text name="variable_133" default="described"]feeling misunderstood and persecuted by others who do not acknoledge their grandiose ideas.
the client[text name="variable_144" default="described"]a pattern of attaning far less sleep than would normally be needed.
the client[text name="variable_155" default="was"]restless and agitated within the session and reports an inabilty to sit quietly and relax.
the client[text name="variable_155" default="gave"]evidence of a short attention span and a high level of distractability.
the client[text name="variable_166" default="reported"]a behavior pattern that refects a lack of normal inhibition and an increase in impulsivity without any regard to potentially painful consequences.
the client[text name="variable_177" default="gave"]evidence of a very expansive mood that can easily turn to impatience and irriability if theyr behavior is blocked or confronted.
the client[text name="variable_188" default="described"] a behavior pattern than reflects a lack of follow-through on many projects.
the client[text name="variable_199" default="exhibits"]The client[text name="variable_w0rry1" default="described"]preoccupation with worry that someting dire will happen
The client[text name="variable_w0rry2" default="described"]symptoms of preoccupation with worry that something dire will happen in response to a resent stressor.
The client[text name="variable_w0rry3" default="described"] symptoms of excessive and unrealistic worry.
The client[text name="variable_w0rry4" default="described"]a history of restlessness, tiredness, muscle tension, and shaking.
The client[text name="variable_w0rry5" default="described"]the presence of symptoms such as heart palpitations, dry mouth, tightness in the throat, and some shortness of breath.
The client[text name="variable_w0rry55" default="described"]occasional tension headaches.
The client[text name="variable_w0rry5q5" default="described"]that they are constantly feeling on edge, that sleep is interrupted, and that concentration is difficult.
The client[text name="variable_w0rry55dsf" default="reported"]being irritable and snappy in interaction with others as their patience is thin and they are worrying about everything.Medications
Past Medications
Medication side effects
Medication adherance
Behavioral health history
Alcohol/ nicotine/ substance/ caffine
Medical history
Review of systems
Legal
Psychosocial
cultural
relationship
exercise
education
job
military
sexual health
currently lving situation/ psychosocial stressors
truama
Assessment /planSan Antonio Therapists
Rosie Ortiz, M.Ed., LPC
Ages: Children & Adults
Specialties: Mood, depression, anxiety, social skills
Insurances: BCBS, Cigna, Optum, and private pay
Location: Here at the Family Wellness Center or virtually
Phone: 830-461-4227
Email: [email protected] Moczygemba, M.A., LPC
Ages: Older adolescents and adults
Insurances: Aetna and Private pay
Specialties: Mood disorders, substance use, trauma, eating disorders
Location: Here at the Family Wellness Center
Phone: 210-293-0883
Website: http://www.alamowellnessgroup.com/Jamie Bundeson, LMFT
Ages: Children & Adults
Specialties: Marriage counseling, Family counseling, individual therapy; mood, depression, anxiety, social skills.
Insurances: BCBS, Humana, UnitedHealthCare, Aetna, private pay. Pending other insurances; call to inquire
Location: Here at the Family Wellness Center; telehealth available
Phone: 210-983-3325
Email: [email protected]
Ages: Children and Adults
Insurances: Aetna, Tricare, BCBS (PPO only), Humana, Ambetter, Gilsbar, United Healthcare, Coresource
Services: Depression, anxiety, play therapy, trauma therapy, group therapy, mood disorders, and multiple other psychological concerns.
Locations: Blanco near 1604, Alamo Ranch Parkway near 1604, and Victoria. In-person and teletherapy available.
Phone: 210-209-0642
Website: https://www.counseling4lifellc.com/Alamo Heights Counseling
Ages: Older teens and adults
Insurances: Multiple, most major insurances.
Services: Trauma, PTSD, depression, anxiety
Location: Near 410 & Broadway
Phone: 210-822-2600
Website: https://www.alamoheightscounseling.com/
Chief complaint:Gender:
The client's preferred pronouns: Pharmacy:Allergies: Reaction:HPI
is a seeking treatment forthat startedand has
The intensity of the symptoms is a on a scale of 0 to 10 with 10 being the most intense and zero being the least intense.
Assocating factors:
Modifing factors:The clients mood has beenover the past two weeks.They reportThey described their appitite as: They have weight. They binging, restrcting, or purging meals.They describe their sleep as
They report they are able to fall and stay asleep.
They denied waking up earlier than they have to.
TheynightmaresTheir energy level has been a on a scale of 0 to 10 with ten being the hightest energy level and zero being the lowest.They energy that does not last throgh the day.They noticing that theri movements really slow down.
They feeling restless, pacing, and ubale to sit down for long.The client feelings of pervasive, irrational guilt
The client negative feelings towards themself and feelings of inadaquecy
The client The client that they are unable to maintain concetration are are easily distracted
The client that hey are unable to read materal with good comprehension because of being seasily disctracted
The client The client SI, HI, and, psychosis.
The client that they are experiencing SIbut have not taken any actionson these thoughts.
The client SI thoughts have resulted in suicidal gestures.
The client any suicidal thoughts or gestures.
The client hallucinations or delusions indicating that the depression has a psychotic component.
the client recurrent thoughts of their own death.
the clientexperiencing recurrent SI, but denied having any specific plan to implement suicidal urges.
the clientexperiencing ongoing SI and has developed a specific plan for SI.
Althoughthe client that they have developed a suicide plan, they indicated that the urge is controllable and promised not to implement such a plan.
the clientmad a suicide attempt within the past the clientan abnormally and persistently elevated, expansive, or irritable mood.
the clienthas been affected by their mania.
the clientevidence of pressured speech within the session.
the client an inability to stay focused on one subject and moved quickly from one topic to another.
the client of grandiose ideas regarding their abilities, plans, and accomplishments
the clientfeeling misunderstood and persecuted by others who do not acknoledge their grandiose ideas.
the clienta pattern of attaning far less sleep than would normally be needed.
the clientrestless and agitated within the session and reports an inabilty to sit quietly and relax.
the clientevidence of a short attention span and a high level of distractability.
the clienta behavior pattern that refects a lack of normal inhibition and an increase in impulsivity without any regard to potentially painful consequences.
the clientevidence of a very expansive mood that can easily turn to impatience and irriability if theyr behavior is blocked or confronted.
the client a behavior pattern than reflects a lack of follow-through on many projects.
the clientThe clientpreoccupation with worry that someting dire will happen
The clientsymptoms of preoccupation with worry that something dire will happen in response to a resent stressor.
The client symptoms of excessive and unrealistic worry.
The clienta history of restlessness, tiredness, muscle tension, and shaking.
The clientthe presence of symptoms such as heart palpitations, dry mouth, tightness in the throat, and some shortness of breath.
The clientoccasional tension headaches.
The clientthat they are constantly feeling on edge, that sleep is interrupted, and that concentration is difficult.
The clientbeing irritable and snappy in interaction with others as their patience is thin and they are worrying about everything.Medications
Past Medications
Medication side effects
Medication adherance
Behavioral health history
Alcohol/ nicotine/ substance/ caffine
Medical history
Review of systems
Legal
Psychosocial
cultural
relationship
exercise
education
job
military
sexual health
currently lving situation/ psychosocial stressors
truama
Assessment /planSan Antonio Therapists
Rosie Ortiz, M.Ed., LPC
Ages: Children & Adults
Specialties: Mood, depression, anxiety, social skills
Insurances: BCBS, Cigna, Optum, and private pay
Location: Here at the Family Wellness Center or virtually
Phone: 830-461-4227
Email: [email protected] Moczygemba, M.A., LPC
Ages: Older adolescents and adults
Insurances: Aetna and Private pay
Specialties: Mood disorders, substance use, trauma, eating disorders
Location: Here at the Family Wellness Center
Phone: 210-293-0883
Website: http://www.alamowellnessgroup.com/Jamie Bundeson, LMFT
Ages: Children & Adults
Specialties: Marriage counseling, Family counseling, individual therapy; mood, depression, anxiety, social skills.
Insurances: BCBS, Humana, UnitedHealthCare, Aetna, private pay. Pending other insurances; call to inquire
Location: Here at the Family Wellness Center; telehealth available
Phone: 210-983-3325
Email: [email protected]
Ages: Children and Adults
Insurances: Aetna, Tricare, BCBS (PPO only), Humana, Ambetter, Gilsbar, United Healthcare, Coresource
Services: Depression, anxiety, play therapy, trauma therapy, group therapy, mood disorders, and multiple other psychological concerns.
Locations: Blanco near 1604, Alamo Ranch Parkway near 1604, and Victoria. In-person and teletherapy available.
Phone: 210-209-0642
Website: https://www.counseling4lifellc.com/Alamo Heights Counseling
Ages: Older teens and adults
Insurances: Multiple, most major insurances.
Services: Trauma, PTSD, depression, anxiety
Location: Near 410 & Broadway
Phone: 210-822-2600
Website: https://www.alamoheightscounseling.com/

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.11, 63 form elements, 834 boilerplate words, 56 text boxes, 3 checkboxes, 1 check lists, 3 drop downs, 77 total clicks
Questions/General site feedback

Send Feedback for this SOAPnote

This site uses Akismet to reduce spam. Learn how your comment data is processed.

More SOAPnotes by this Author: