PROGRESS NOTE 08.16.22 FINAL
AGENDA: [checkbox name="cb6" value="Review homework|Review assessments, screeners, and scoring|Assess mood/functioning|Assess relationship distress|Observe couple communication|Assess sexual functioning/concerns|Psychoeducation|Psychosexual education|Communication skills training|Emotion regulation skills training|Behavioral health interventions|Stress management|Safety planning|Review of Progress|Review diagnostic conclusions/recommendations|Treatment planning|Goal setting|Termination"] ASSESSSMENTS, SCREENERS, & SCORING [checkbox name="cb7" value="Self-report and Behavioral Observation|PHQ-9|GAD-7|Compulsive Sexual Behavior Inventory (CSBI-13)|DAS|DSCS|PCS|FGSIS|International Index of Erectile Function (IIEF)"] UPDATE [textarea name="variable_1" default="Client reported"] SESSION ISSUES/TOPICS DISCUSSED The following tropics/concerns were discussing in session: [checkbox name="cb8" value="Reviewed homework/assignment follow-up|Current symptoms/functioning|Symptom management|Management of depression symptoms|Management of anxiety symptoms|Emotion dysregulation|Anger issues|Emotional expression concerns|Distress intolerance|Adjustment to a stressor(s) |Grief/Loss Relationship distress|----------|Attachment issues|Fear and/or avoidance of developing intimate relationships|Relationship dissatisfaction|Relationship argument or regrettable incident with partner|Relationship intimacy concerns|Infidelity/affair concerns|Divorce issues|Relationship trust issues|Intimate partner violence|Power and control issues|Stalking concerns|----------|Interpersonal ineffectiveness|Boundary setting|Conflict with peers|Conflict with family|Conflict with coworker(s)|----------|Sexual functioning concerns|Sexual health concerns|Sexual behavior(s) of concern|Sexual orientation/identity concerns|Sexual orientation microaggressions|Internalized homophobia|Sexual relationship dissatisfaction|Sexual communication comfort|Sexual scripts/sexual script adjustment|----------|Fertility concerns|IVF-related stress|Pregnancy concerns|Delivery/post-delivery concerns|Peri/post menopause issues|Hormone therapy issues|Cancer and sexuality concerns|Age and sexuality concerns|----------|Gender-related concerns|Gender dysphoria|Gender expression|Gender identity concerns|Gender affirming medical treatment(s)|Coming out concerns|----------|Minority stress|Sexual minority stress/stigma|Transgender microaggressions|Internalized transgender hatred|Internalized prejudice and discrimination|Racism|Sexism|Sexual harassment|Occupational stereotypes/discrimination|----------|Behavioral health issues|Self-Care/hygiene issues|Sleep hygiene|Weight management|Physical activity/exercise|----------|Substance use concerns|Alcohol use concerns|Cannabis use concerns|Tobacco use concerns|----------|Trauma event|Sexual trauma event|Child abuse|----------|Stressors|Stressor/coping mechanism(s)|Familial relationship distress|Work problems|Financial issues|Legal Issues|Housing issues|Parenting stress|----------|Medical/health concerns|Disease management|Medication concerns|Health anxiety|----------|Religious/spiritual concerns"]. ENDORED SYMPTOMS The following symptoms were endorsed: [checkbox name="cb9" value="Depressed mood|Sadness|Loss of interest in pleasurable activities|Tearful or crying spells|Fatigue/low energy|Difficulty sleeping|Trouble falling asleep|Appetite changes|Weight changes|Trouble concentrating|Low motivation|Isolation from others|Loneliness|Low self-esteem|Suicidal ideation|----------|Anxiety/Worry|Anxiety of social situations|Anxiety of social interactions|Concerns of negative evaluation by others|Fear of embarrassing self|Panic/Abrupt surge of intense fear/intense discomfort|Worry about having future panic symptoms/attacks|Sweating|Nausea|Difficulty concentrating|Muscle tension|Difficulty controlling worry|Worry about every, routine life circumstances|Worry about job responsibilities|Worry about health|Worry about finances|Panic attacks|Fear|Hopelessness|Pain|Anger|Impulsivity|Hypervigilance|Grief|----------|Worry about the future|Worry about future of relationship|Worry about infidelity|Low self-esteem|Low self-confidence|Decreased sense of masculinity|Fear/avoidance of future sexual encounters|Decreased sexual satisfaction|Reduced sexual desire|Absent sexual desire|Pain with sexual activity|Delayed ejaculation|Orgasm difficulty|Arousal difficulty"]. ENDORSED IMPAIRMENTS The following areas of impairment were endorsed: [checkbox name="cb10" value="Completing life tasks/responsibilities|Isolation|Health|Sleep|Nightmare(s)|Financial|Relationship difficulties|Conflict with others|Not completing work-related responsibilities|Decreased work productivity|Decrease in self-care|Sexual functioning"]. THERAPEUTIC INTEVENTIONS USED Provider used the following interventions: [checkbox name="cb11" value="Active listening and feedback|Validated and normalized emotions|Supportive reflection|Open-ended questions|Socratic questioning|Self-disclosure|Bibliotherapy|Psychoeducation|Psychosexual education|Exploration of sexual history|--------|CBT therapy modalities|Cognitive challenging|Cognitive refocusing|Cognitive restructuring|Identification/modification of dysfunctional Assumptions/biases|Identify distorted automatic thoughts|--------|Communication skills to address interpersonal concerns|Assertive communication skills|--------|Sex therapy interventions|Sensate Focus|--------|Transgender and gender nonconforming (TGNC)-affirmative interventions|Psychoeducation about genderqueer and queer terms|Reviewed the Gender Unicorn|Definitions of sex, gender identity, and sexual orientation|Supported exploration of gender expression|Reviewed WPATH standards of care|Provided psychoeducation on medical options for gender affirmation|Feminist interventions|Empowerment and social advocacy interventions|Social and gender role analysis|--------|Gottman Method Couple Therapy Interventions|Gottman Love maps|Psychoeducation on building fondness and admiration|Turning toward instead of away|Psychoeducation about increasing awareness of emotional bids|Identifying the Four Horsemen|Encouraging a gental approach|Psychological soothing for flooding|Establishing formal and informal ritual of connection|Process the aftermath of an argument or regrettable incident|Exlpore pattern of closeness and distance|Explore communication cycle|Observe and provide feedback on Couple communication|--------|DBT/Emotion regulation skills|DBT/Distress tolerance skills|DBT/Interpersonal effectiveness skills|Exploration of coping patterns|Exploration of emotions|Exploration of relationship patterns|Exploration of maladaptive cyclical patterns|Interpersonal Interventions|Interactive feedback/process comments|Mindfulness Training |Pain Management|----------|Motivation interviewing to assess readiness for change|Smoking cessation|Alcohol use interventions|----------|Exploration of family of origin /dynamics|Role play|-------|Behavioral health interventions|Sleep hygiene interventions|Behavioral activation|SMART Goals|--------|Stress management interventions (i.e., deep breathing, PMR)|Subjective Unit of Distress (i.e., SUDs)|Progressive muscle relaxation|Guided imagery|Diaphragmatic breathing"]. TREATMENT PROGRESS/PROGRESS TOWARDS TREATMENT GOALS Client progress in achieving treatment goals is best assessed as - [checkbox name="cb12" value="responding well to interventions|making some progress|slow/slight progress|fluctuating/intermittent progress|maintaining past gains|maintaining current goal focus|reprenting relapse|an increase in symptoms|a decrease in symptoms|a significant excalation in symptoms|minimal|improving|stable"] - as evidenced by Client self-report, behavior, and engagement. ADDITIONAL SESSION INFORMATION [textarea name="variable_10" default=""] HOMEWORK [textarea name="variable_2" default="sample text"] RISK FACTORS [checkbox name="cb13" value="No SI/HI indicated|No SI/HI reported|SI/HI denied|----------|Suicidal Ideation|No SI reported|SI Denied|Endorsed Suicidal Ideation|Endorsed Non-suicidal Morbid Ideation|Endorsed Active Suicidal Ideation with a Method but without Plan or Intent to Act|Endorsed Suicide Attempt|Endorsed Nonsuicidal Self-Injury|----------|No homicidal ideation reported|Homicidal ideation denied|Endorsed Homicidal Ideation|Endorsed Non-Homicidal Morbid Ideation|Endorsed Active Homicidal Ideation with a but without Plan or Intent to Act|Endorsed Homicidal Attempt"] MENTAL STATUS EXAM Orientation: [select name="MSE_1" value="Alert and oriented X4|unable to assess due to cognitive impairment"]; Affect: [select name="MSE_2" value="Full range|Flat|Tearful at times|Flat, tearful & congruent with depressed & anxious mood|Appropriate to mood and thoughts|Inapporpriate to mood and thoughtsRestricted in range and mood congruent"]; Observations: [select name="MSE_3" value="WNL|Crying|Mild agitation when discussing stressor|moderate agitation when discussing stressor|yawning|left room"]; Speech: [select name="MSE_4" value="WNL|Normal rate and rhythm, not pressured|Pressured at times|soft"]; Behavior: [select name="MSE_5" value="WNL|Left room to use bathroom"]; Thought process: [select name="MSE_6" value="WNL|Logical, linear, goal directed|circumstantial|Circumstantial but redirectable|Tangential"]; SI/HI: [select name="MSE_7" value="Not indicated|denied|SI endorsed/HI denied"] FOLLOW-UP PLAN: [checkbox name="cb14" value="RTC in 1 week to assess mood/functioning, review homework, and goal setting|RCT in 1 week to assess relationship distress, review homework, and goal setting|RTC in 1-2 weeks to assess mood/functioning, review homework, and goal setting|RTC in 1-2 weeks to assess relationship distress, review homework, and goal setting|RTC in 1 month to assess mood/functioning, review homework, and termination planning|Client will contact Provider to schedule next session.|Provider will contact Client to schedule next session."]
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