Outpatient Assessment Note (one person)

Subjective

Client completed all intake paperwork.  Reviewed with client limits to confidentiality, potential benefits and drawbacks of treatment, communication outside of session and attendance policies. Obtained consent for treatment. Discussed biopsychosocial history further and completed all intake paperwork. Assessed reason for treatment, current struggles and symptoms.

Identified with client presenting problem [textarea name="variable_3" default="sample text"]
Identified with client creation of goals including: [textarea name="variable_5" default="sample text"]
Discussed with client current plan to obtain goals including: [textarea name="variable_6" default="sample text"]

Other concerns discussed in session include: [textarea name="variable_8" default="sample text"]


Objective
Current Diagnosis: [text name="variable_1" default="sample text"]
Current chief complaints / Symptoms : [textarea name="variable_10" default=" "]

Apperance: [checkbox name="variable_1" value="Casual / Normal| Poor or lacking| Other"] [text name="variable_4" default=" "]

Attitude: [checkbox name="variable_2" value="Calm | Cooperative| Uncooperative| Frustrated| agitated "]

Behavior: [checkbox name="variable_3" value="No unusual movements or psychomotor changes| Unusual movements or psychomotor agitation"] [text name="variable_8" default=" "]

Speech: [checkbox name="variable_9" value="Normal rate / tone | Abormal | Tangential| Focused| Lacking| Intense| Quiet| Loud"]

Affect: [checkbox name="variable_11" value="Euthymic| Irritable| Elevated| Anxious | Depressed | Other "] [text name="variable_13" default=" "]

Thoguht Process: [checkbox name="variable_20" value="Concerns | No Concerns"]

Suicidal Ideation: [checkbox name="variable_88" value="No | Yes| Plan | Intent| Means"]

Homicidal Ideation:[checkbox name="variable_89" value="No | Yes| Plan | Intent| Means"]

Perception: [checkbox name="variable_90" value="No hallucinations or delusions during interview | Other"] [text name="variable_1000" default=" "]

Orientation: [checkbox name="variable_200" value="time | Place | Person | Self"]

Memory: [checkbox name="variable_201" value="Short Term intact | Long term intact| Distractable"]

Judgement [checkbox name="variable_202" value="Good | Fair| Poor"]

Assessment

Client presents as: [textarea name="variable_999" default="sample text"]
Reports history of mental health treatment: [textarea name="variable_991" default="sample text"]
Movement towards goals include: [textarea name="variable_992" default="sample text"]
Therapist interpretation of assessment: [textarea name="variable_993" default="sample text"]
Client continues to struggle with: [textarea name="variable_994" default="sample text"]
Client presents with movement [select name="variable_1" value="Towards | Away"] from therapeutic goals 

Plan: 
Client will continue with outpatient therapy PRN. Therapist will assist client in identifying the appropriate weekly “homework” tasks before the end of each session. Client will complete / attempt: [textarea name="variable_9999" default="sample text"] Proir to next session.
Next session (S): [textarea name="variable_888888" default="sample text"]
Subjective

Client completed all intake paperwork. Reviewed with client limits to confidentiality, potential benefits and drawbacks of treatment, communication outside of session and attendance policies. Obtained consent for treatment. Discussed biopsychosocial history further and completed all intake paperwork. Assessed reason for treatment, current struggles and symptoms.

Identified with client presenting problem

Identified with client creation of goals including:

Discussed with client current plan to obtain goals including:


Other concerns discussed in session include:



Objective
Current Diagnosis:
Current chief complaints / Symptoms :


Apperance:

Attitude:

Behavior:

Speech:

Affect:

Thoguht Process:

Suicidal Ideation:

Homicidal Ideation:

Perception:

Orientation:

Memory:

Judgement

Assessment

Client presents as:

Reports history of mental health treatment:

Movement towards goals include:

Therapist interpretation of assessment:

Client continues to struggle with:

Client presents with movement from therapeutic goals

Plan:
Client will continue with outpatient therapy PRN. Therapist will assist client in identifying the appropriate weekly “homework” tasks before the end of each session. Client will complete / attempt:
Proir to next session.
Next session (S):

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.43, 30 form elements, 161 boilerplate words, 5 text boxes, 12 text areas, 12 checkboxes, 1 drop downs, 66 total clicks
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