Psychiatry & Psychology
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SESSION DATE: [date name="Date"]

POS: [checkbox name="variable_1" value="Code: 02 (Telehealth)|Code: 11 (Office)"]

PRESENT IN SESSION:
[checkbox name="cb1" value="Client |Client and Partner |Partner without Client |Client with Support Individual |Other"]

CPT CODE/TYPE OF TREATMENT:
[checkbox name="cb2" value="90837, 95 - Individual Psychotherapy|90847, 95 - Family/Couple Psychotherapy with patient present|90846, 95 - Family/Couple Psychotherapy, without patient present|----------|90837 - Individual Psychotherapy|90847 - Family/Couple Psychotherapy with patient present|90846 - Family/Couple Psychotherapy, without patient present|----------|90785- Interactive Complexity: (i.e., Communication difficulties present during current the psychiatric procedure): The need to manage maladaptive communication (e.g., high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicated the delivery of care."]

DIAGNOSIS/-ES (FOCUS OF TREATMENT):
[checkbox name="cb3" value=" (V61.10) (Z63.0) Relationship Distress with Spouse or Intimate Partner|----------|(309.0) (F43.21) Adjustment Disorder with Depressed Mood|(309.24) (F43.22) Adjustment Disorder with Anxious Mood|(309.28) (F43.23) Adjustment Disorder with Mixed Anxiety and Depressed Mood|----------|(311) (F32.9) Unspecified Depressive Disorder|(296.31) (F33.0) Major Depressive Disorder, recurrent, mild|(296.32) (F33.1) Major Depressive Disorder, Recurrent, Moderate|(296.33) (F33.2) Major Depressive Disorder, Recurrent, Severe|(F32.89) Other Specified Depressive Disorder|R/O Depressive Disorder|R/O Major Depressive Disorder|----------|(300) (F41.9) Unspecified Anxiety Disorder|(300.02) (F41.1) Generalized Anxiety Disorder|(300.23) (F40.10) Social Anxiety Disorder|R/O Anxiety Disorder|R/O Generalized|Anxiety Disorder|R/O Social Anxiety Disorder|----------|(302.79) (F52.8) Unspecified sexual dysfunction| (302.74) (F52.32) Delayed Ejaculation| (302.72) (F52.21) Erectile Disorder, acquired, generalized, moderate|(302.71)(F52.0) Male Hypoactive Sexual Desire Disorder, Acquired, Situational, Moderate|(302.73) (F52.31) Female orgasmic disorder, life long, generalized, moderate, never experienced an orgasm under any situation|(302.76) |(F52.6) Genito-Pelvic Pain/Penetration Disorder, lifelong, moderate|(302.72) (F52.22) Female Sexual Interest/Arousal Disorder, acquired, generalized, moderate|(302.85) (F64.0)|----------|Gender Dysphoria in Adolescents and Adults|(302.6) (F64.9) Unspecified Gender Dysphoria|----------|(312.89) (F91.8) Other Specified Disruptive, Impulse-Control, and Conduct Disorder|(291.9) (F10.99) Unspecified Alcohol-Related Disorder|----------|(V61.10) (Z63.0) Relationship Distress with Spouse or Intimate Partner"]

OTHER DIAGNOSIS/-ES (NOT FOCUS OF TREATMENT):
[checkbox name="cb4" value=" (V61.10) (Z63.0) Relationship Distress with Spouse or Intimate Partner|----------|(309.0) (F43.21) Adjustment Disorder with Depressed Mood|(309.24) (F43.22) Adjustment Disorder with Anxious Mood|(309.28) (F43.23) Adjustment Disorder with Mixed Anxiety and Depressed Mood|----------|(311) (F32.9) Unspecified Depressive Disorder|(296.31) (F33.0) Major Depressive Disorder, recurrent, mild|(296.32) (F33.1) Major Depressive Disorder, Recurrent, Moderate|(296.33) (F33.2) Major Depressive Disorder, Recurrent, Severe|(F32.89) Other Specified Depressive Disorder|R/O Depressive Disorder|R/O Major Depressive Disorder|----------|(300) (F41.9) Unspecified Anxiety Disorder|(300.02) (F41.1) Generalized Anxiety Disorder|(300.23) (F40.10) Social Anxiety Disorder|R/O Anxiety Disorder|R/O Generalized|Anxiety Disorder|R/O Social Anxiety Disorder|----------|(302.79) (F52.8) Unspecified sexual dysfunction| (302.74) (F52.32) Delayed Ejaculation| (302.72) (F52.21) Erectile Disorder, acquired, generalized, moderate|(302.71)(F52.0) Male Hypoactive Sexual Desire Disorder, Acquired, Situational, Moderate|(302.73) (F52.31) Female orgasmic disorder, life long, generalized, moderate, never experienced an orgasm under any situation|(302.76) |(F52.6) Genito-Pelvic Pain/Penetration Disorder, lifelong, moderate|(302.72) (F52.22) Female Sexual Interest/Arousal Disorder, acquired, generalized, moderate|(302.85) (F64.0)|----------|Gender Dysphoria in Adolescents and Adults|(302.6) (F64.9) Unspecified Gender Dysphoria|----------|(312.89) (F91.8) Other Specified Disruptive, Impulse-Control, and Conduct Disorder|(291.9) (F10.99) Unspecified Alcohol-Related Disorder"]

SESSION MINUTES:
[checkbox name="cb5" value="53|55|60|90|120"]

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"]

ASSESSSMENTS, SCREENERS, & SCORING:
[checkbox name="cb7" value="Self-report and Behavioral Observation|PHQ-9|GAD-7|DAS|DSCS|PCS|FGSIS|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
Client endorsed the following symptoms: [checkbox name="cb9" value="Depressed mood|Sadness|Loss of interest in pleasurable activities|Tearful or crying spells|Fatigue/low energy|Difficulty sleeping|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 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|Orgasm difficulty|Arousal difficulty"].

Impairments Endorsed:
Client reported the following impairments: [checkbox name="cb10" value="Completing life tasks (i.e., )|Health|Sleep|Nightmare(s)|Financial|Relationship difficulties|Conflict with others|Not completing work-related responsibilities|Decreased work productivity|Decrease in self-care"].

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|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)|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 evidence by Client self-report, behavior, and engagement.

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"]

MSE:
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"]; Observed: [select name="MSE_3" value="WNL|Crying|Mild agitation when discussing stressor|moderate agitation when discussing stressor|yawning"]; 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."]
SESSION DATE:

POS:

PRESENT IN SESSION:


CPT CODE/TYPE OF TREATMENT:


DIAGNOSIS/-ES (FOCUS OF TREATMENT):


OTHER DIAGNOSIS/-ES (NOT FOCUS OF TREATMENT):


SESSION MINUTES:


AGENDA:


ASSESSSMENTS, SCREENERS, & SCORING:


UPDATE:


SESSION ISSUES/TOPICS DISCUSSED:
The following tropics/concerns were discussing in session: .

ENDORED SYMPTOMS
Client endorsed the following symptoms: .

Impairments Endorsed:
Client reported the following impairments: .

THERAPEUTIC INTEVENTIONS USED
Provider used the following interventions: .

TREATMENT PROGRESS/PROGRESS TOWARDS TREATMENT GOALS:
Client progress in achieving treatment goals is best assessed as as evidence by Client self-report, behavior, and engagement.

HOMEWORK:


RISK FACTORS:


MSE:
Orientation: ; Affect: ; Observed: ; Speech: ; Behavior: ; Thought process: ; SI/HI:


FOLLOW-UP PLAN:

Result - Copy and paste this output:
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