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Client Name: [text name="name" default="client name"] Session Date: [date name="date" default="00/00/2022"] Session Time: [text name="variable_1" default="time"] [select name="time" value="AM|PM"] Session Length: [select name="time elapse" value="15 minutes|30 minutes|45 minutes"] Mode of Treatment [checklist name="Mode of Treatment" value="Individual|Couples|Family|Group"] Session Format [checklist name="format" value="In Person|Teletherapy Audio|Teletherapy Video|Other"] [text name="variable_2" default="sample text"] Session Frequency [checklist name="frequency" value="1x/week|2x/week|1x/month|2x/month|Other"] [text name="variable_3" default="sample text"] Client's location of current physical address: [select name="state" value="Maryland|California|Other"] [text name="variable_4" default="sample text"] Therapeutic Interventions [checkbox name="intervention" value="Psychodynamic|Cognitive Behavioral|Attachment-Oriented|Behavioral|Crisis Intervention|Modeling and Skills Training|Psychoeducation|Therapeutic Exercises and Activities|Mindfulness|Supportive|Other"] [text name="variable_5" default="sample text"] Target Problem Areas Identified Narrative Session Summary [textarea name="summary" default="sample text"] Next Appointment Scheduled: [date name="date_2" default="00/00/2022"], [text name="variable_7" default="time"] Treatment Goals [checklist name="variable_9" value="option="Reduce distress in identified problem areas.|Symptom stabilzation.|Enhance self-awareness."] Treatment Objectives [checklist name="objectives" value="Explore and understand the influence of the past on present behavior and emotions.|Examine and repair unresolved conflicts.|Recognize and address defense mechanisms.|Recognize and challenge cognitive distortions.|Learn and utilize healthy coping strategies."] Recommendations 1) Client will attend all scheduled individual teletherapy appointments. 2) Client will contact therapist with any questions/concerns that may arise between sessions. 3) Client will notify therapist if change in safety risk occurs and will follow safety plan in event of crisis. 4) Client will complete weekly assignments. 5) Client will engage in weekly reflective journaling. Homework Assignment: [text name="homework" default="homework"]
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Sandbox Metrics: Structured Data Index 0.55, 20 form elements, 92 boilerplate words, 8 text boxes, 1 text areas, 2 dates, 1 checkboxes, 5 check lists, 3 drop downs, 44 total clicks
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