IN PROGRESS MH Progress Note

•Patient• [text name="Name" default=""]
•Session Date• [date name="variable_1" default="today"]
•Begin Time• [text name="Begin_Time" default=""]
•End Time• [text name="End_Time" default=""]
•Session Duration• [calc value="score1=(End_Time)-(Begin_Time)"] minutes
•Service Code• [checkbox name="90791" value="90791" memo="Intake/Assessment"][checkbox name="90832" value="90832" memo="16-37 minutes"][checkbox name="90834" value="90834" memo="38-52 minutes"][checkbox name="90837" value="90837" memo="53-89 minutes"][checkbox name="90846" value="90846" memo="Family w/o patient present, 50 minutes"][checkbox name="90847" value="90847" memo="Family/conjoint w/ patient present, 50 minutes"][checkbox name="90853" value="90853" memo="Group Therapy"][checkbox name="90839" value="90839" memo="Crisis (up to 90 minutes)"][checkbox name="90840" value="90840" memo="+ Crisis (each add'l 30 min block beyond initial 74 min)"][checkbox name="90840" value="90840" memo="+ Crisis (each add'l 30 min block beyond initial 74 min)"][checkbox name="90785" value="90785" memo="+ Interactive Complexity due to maladaptive communication, use of interpreter, caregiver emotions or behavior interfere with visit, mandated report to 3rd party, required contact with school or probation/parole (use with 90791, 90832, 90834, 90837, or 90853)"][text]
•Medical necessity factors influencing length and/or frequency of sessions• [checkbox name="extended_reasons" value="to address new symptoms or re-emergence of old symptoms|assessment and stabilization|rapport building with client|significant trauma history necessitates additional time for disclosure and containment|to address complicated issues related to diagnoses and clinical presentation|grounding needed for symptoms that emerged during session|reviewed homework|client requested longer session due to decreased frequency of sessions|to prevent escalation to more intensive level of care|client crisis/acute issue|utilizing exposure therapy for ptsd, panic disorder, OCD or specific phobia|an unexpected complication resulting from pharmacotherapy|parental involvement for psychoeducation or anger management skills|BPD diagnosis requiring DBT sessions|for rapport building with new client|the client requesting additional session time and or increased frequency|a history of trauma|time necessary to address and contain intense emotional content|preventative measures to avoid higher level of care|necessary for the therapeutic intervention utilized in session|addressing new or re-emerging symptoms|limited health support network|client is unable to share content with others in support system due to nature of topic|EMDR Protocol being utilized|bi-weekly sessions|monthly sessions to maintain acquired skills|symptoms are impacting multiple domains of life (Relationships, work, school community)|IFS Protocol being utilized"].[text]
•Modality/Type of Contact• [checkbox name="Mode" value="Individual|Family|Group|Collateral"].[text]
•Seen With• [checkbox name="Attendees" value="N/A|mother|father|siblings|significant other|parent|guardian|family member|grandparent|foster parent|case worker"].[text]
•Purpose of Contact/Related Goals Addressed• [checkbox name="Goals" value="symptom reduction|skill acquisition|improve functioning|improve health|maintain positive gains|reduce ineffective behaviors"].[text]
•Clinical Observations• [checkbox name="Clin_obs" value="angry|agitated|anxious|appropriate|blunted|calm|delusional|distracted|downcast|engaged|guarded|happy|inappropriate|lethargic|quiet|sad|sullen|tearful|verbal|appeared generally positive|calm and reflective|dysphoric|mildly depressed|moderately depressed|marked by hopelessness|detached|mildly anxious|moderately anxious|increased motor activity|improved reflective capacity|improved judgment|a post-traumatic reaction|orientation x4 within constrains of developmental stage"].[text]
•Impact of Symptoms on Functional Status•
--Relational: [select name="Rel" value="Low|Moderate|High"]
--Occupational/School: [select name="Occ_Edu" value="Low|Moderate|High"]
--Physical: [select name="Phy" value="Low|Moderate|High"]
•Risk• [checkbox name="Risk" value="No evidence or report of suicidal or homicidal ideation|Patient denies suicidal or homicidal ideation|Evidence of suicidal ideation|Evidence of homicidal ideation|NSSI|Other Safety Concerns|Client participated in safety planning or creating a risk management plan"].[text]
•Primary Clinical Interventions and Strategies Implemented• [checkbox name="Interventions" value="Cognitive/behavioral techniques|Emphasis on self-expression|Normalization|Psycho-education regarding symptom-management and skill building|Play Therapy|Interpretation|Parent Education|DBT-Informed|Validation|Rapport Building|Emotional Expression|Relaxation Techniques|Supportive Therapy|Increase Coping|Identify/Reframe Thinking|Problem-solving|Positive Reinforcement|Communication Skills|Identify Triggers|Clarification|Behavioral Rehearsal|Assertiveness Training|Art Therapy|Child Behavioral Strategies|Reframing|Active Listening|Setting Appropriate Boundaries|Tx Plan Review|Strengthen Support Systems|Family Hx/Dynamics|Trauma-informed Interventions|Role Play|Modeling|Child-centered Play Therapy Techniques|TF-CBT|Cognitive Re-structuring|Family Therapy|Expressive Arts|Focus on Improved Problem Solving and Coping|Expressive Art Techniques|Supportive Techniques|Emphasis on Here-and-Now Functioning|Evaluation and Exploration of Problematic Automatic Thoughts|Targeting More Effective Problem Solving and Coping Skills in Daily Life|Addressing Problematic Core Beliefs|Evaluating and Addressing Dysfunctional Thoughts|Emphasis on Self-Monitoring of Thoughts, Emotions and Behavior|Techniques for the Development of Greater Confidence and Self-Efficacy|Self-Assertiveness and Confidence Building|A Focus on Anger Management and Containment of Acting Out|Exploration of Appropriate Interaction and Communication|Focus on Social Skills Enhancement and Practice|Guided Imagery Used to Improve Mindfulness and Improve Impulse-Control|Review Informed Consent/Confidentiality"].[text]
•Progress and Effectiveness• [checkbox name="Progress" value="Regressed|No notable change|Slight progress|Some progress apparent|Fluctuating/intermittent progress|Significant improvement|Maintaining past gains/stable|Near completion of treatment|Current focus on maintenance/relapse prevention|Some increase in symptoms|Significant increase in symptoms|Progress with self-understanding and self-insight|There is continued development of the clients capacity for self-care and life management|Developments continue in the areas of family and relational functioning|Developments continue in the areas of occupational functioning and achievement|Developments continue in the areas of healthy separation and interdependence|Developments continue in the area of containment of harmful acting out behavior|The client continues to make steady gains in self-esteem and confidence|A significant reduction in symptoms continues|Client actively participated in the counseling process and in development client-centered treatment plan|Client was active and communicative throughout the process and responded well to the intervention offered|Treatment continues to show good evolution and development|Current crisis has overwhelmed client’s resources"].[text]
•Response to Intervention• [checkbox name="RTI" value="Minimal|Problematic|Adequate|Moderate|Excellent|Engaged in the therapeutic process"].[text]
•Ongoing Plan• [checkbox name="Plan" value="Treatment to continue as indicated|Increase/Decrease session frequency|Move toward discharge|Discharge|Referral|Higher level of care needed|Follow up|Homework|Practice Skill|Follow Up appointment scheduled|Client/Guardian will call to schedule follow up appointment"].[text]
Jessica Dorner, LPC
Mental Health Therapist
•Session Date•
•Begin Time•
•End Time•
•Session Duration• score1=(End_Time)-(Begin_Time) minutes
•Service Code• Intake/Assessment 16-37 minutes 38-52 minutes 53-89 minutes Family w/o patient present, 50 minutes Family/conjoint w/ patient present, 50 minutes Group Therapy Crisis (up to 90 minutes) + Crisis (each add'l 30 min block beyond initial 74 min) + Crisis (each add'l 30 min block beyond initial 74 min) + Interactive Complexity due to maladaptive communication, use of interpreter, caregiver emotions or behavior interfere with visit, mandated report to 3rd party, required contact with school or probation/parole (use with 90791, 90832, 90834, 90837, or 90853)
•Medical necessity factors influencing length and/or frequency of sessions• .
•Modality/Type of Contact• .
•Seen With• .
•Purpose of Contact/Related Goals Addressed• .
•Clinical Observations• .
•Impact of Symptoms on Functional Status•



•Risk• .
•Primary Clinical Interventions and Strategies Implemented• .
•Progress and Effectiveness• .
•Response to Intervention• .
•Ongoing Plan• .

Jessica Dorner, LPC
Mental Health Therapist

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