Psychiatry
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Current Psychotherapy [textarea] psych/ med Mgmt
psych Hospitalizations
Php/Partial Hospitalization
Outpatient Tx
Family Member Had Outpatient Psychotherapy
Individual & Group MH Evaluation & Tx (Psychotherapy)
Rehab/Other Therapies
Behavioral Health Austism Spectrum Disorder, Aba Services
Crisis Intervention
Counseling From Therapist At Primary Care Clinic
Psychological Testing To Evaluate MH Condition
MH & etoh Use Screening & Counseling (Screening, Brief Intervention, Referral, & Tx, “Sbirt”)
psych Consultation
Individual & Group MH
Recreational [/textarea]
Focus Of Psychotherapy:[textarea] Interpersonal Conflict
Emotional Experience Related To Dx
Identification Of Coping Mechanisms
Grief Counseling [/textarea]
Modality: [textarea] Insight Oriented
Supportive
Behavioral Modification [/textarea]
Prior tx: [textarea] Psychotherapy
med & Psychotherapy
Long Term Psychotherapy
Short Term Psychotherapy
Supportive Psychotherapy
Psychodynamic Psychotherapy
Cognitive Behavioral Therapy /CBT
Dialectical Behavior Therapy Skills Training
Drama Psychotherapy
Existential Psychotherapy
Exposure & Response Prevention Therapy
Cognitive Processing Therapy
-Centered Therapy [/textarea]
VERBS [textarea] Asked
Discussed consequences
Examined benefits/consequences
Gave Homework:
Inquired about
Led in practicing
Listened Closely
Affirmed
Paraphrazed
Pointed out
Provided insight
Questioned openly
Reframed
Responded to
Validated
Monitored
Maintained
offered feedback
analyzed
reality tested
examined
re-framed
role-modeled
consulted
supported
demonstrated
Clarified / sought clarification
Assisted in
Contracted
Gave homework assignment
Reinforced
Summarized
Paraphrased
Pointed out consequences
Validated ’s point of view / feelings
Examined benefits / consequences
Questioned (openly)
Led in practicing [/textarea]
COMMON [textarea] conducted mental status exam
modeled _ technique
used _ exercise
modeled technique
used exercise
helped reflect on progress made so far on
coached on
Addressed concerns
help feel more
ensure access services
Monitoring progress[/textarea]
Active Listening/Rapport Building[textarea] Empathic responses to promote safety, expression of material & development of rapport
Attentive listening, open-ended questions to facilitate expression of material
help articulate feelings about
encourage to share thoughts around
used open ended questions
Validated point of view feelings
Engaged in positive social interaction
Provided active listening
asked open ended question to explore hx[/textarea]
Exploration of [textarea] Coping Patterns
Emotions
Relationship Patterns [/textarea]
Psychoeducation[textarea] Psycho-educational techniques rendered to assist in better understanding of
educated
Education about how sx problem behaviors might be managed [/textarea]
MI[textarea] utilized MI techniques to increase motivation to change
MI techniques to assist in identification of available solutions & adaptive problem-solving
MI techniques to help identify obstacles & opportunities for change [/textarea] CBT [textarea] Utilize CBT techniques to assist in challenging anxiety & agoraphobia
Use Cognitive Restructuring techniques to re-frame challenges & difficult feelings to positive outlooks for self
identifying anxiety provoking trigger
Redirect to healthy cognition & behavior
assist in Identify unhealthy cognition & behavior [/textarea]
BEHAVIORAL [textarea] acknowledged success in
reviewed current coping w/
help practice appropriate behavior in
Commended
Prompted [/textarea] MINDFULNESS/COPING SKILLS [textarea] encouraged to practice "STOP BREATHE THINK" before making impulsive decision
utilized mindfulness techniques w/ to help calm down
learn to better manage
assisted in making backup plan for reinforced current plan, including taking walks calling friends watching funny movies when in crisis to decrease feelings of hopelessness anxiety
utilized mindfullness techniques
ensure has sufficient support
Led in practicing [/textarea] INTERPERSONAL [textarea] practiced assertive communication skills to increase interpersonal effectiveness
assist in developing assertive communication skills & implementing boundaries in relationships
modeled appropriate communication skills[/textarea] PROBLEM SOLVING[textarea] worked to identify long term goals & assisted in identifying priorities & how to help get there
assisted in identifying wants vs needs in planning for priorities
modeled problem solving steps to to help decide best way to
discussed triggers that caused setbacks, such as
assist in achieving goals
Assisted in developing
Brainstormed w/
help make plan around
help overcome obstacles [/textarea]
[textarea name="variable_1" default="psychodynamic]
[textarea] med MGMT
educated about meds & how can reduce sx of RISK MGMT [/textarea] [textarea] educated about risks & consequences of current choices[/textarea]
Psycho-Social Interventions: [textarea] Art Therapy
Behavior Modification
CBT / Cognitive Therapy; Behavioral Therapy
Choice Making
Cognitive Challenging / Refocusing / Reframing
Cognitive Processing Tx
Coping
Couple Therapy
Crisis Intervention
Day Tx Program
DBT
Desensitization
Dialectical Behavior Tx Skills Training
Ego-State Therapy
Emdr
Emotion-Focused Therapy
Exposure & Response Prevention Tx
Family Therapy
Family Tx
Grief Work
Group Therapy
Guided Imagery
Hypnosis
Individual Therapy
Interactive Feedback
Interpersonal Resolutions
Interpersonal Rhythm Social Therapy
IPT
Journaling Homework
Limit Setting
Logotherapy
Meditation
Mindfulness
Mindfulness CBT
Mindfulness Training
Play Tx
Positive Reinforcement
Preventative Services
Psychoanalysis
Rapport Building
Reading Homework
Reality Testing
Redirection
Reframing
Relaxation Therapy
Short Term Psychodynamic
Skills/Relaxation Training
Solution Focused
Supportive Interaction
Supportive Therapy
Supportive Tx
Sx Mgmt/Coping
Transfer Financial Capicity
Transfer Tx Capacity
Transference Focused Therapy
Vocational Training [/textarea] Measurable Objectives Include: [textarea] Decrease in suicidality & self harm
Process grief w/ increased painful affect
Identification of early signs of decompensation of psych condition [/textarea]
Work on [textarea] initiating new relationships
assertiveness
improved communication in relationships
intimacy
self esteem regulation
socialization (including utilizing social supports) [/textarea] Psychotherapy Homework [textarea] Behavioral activation homework: [specify]
Behavioral experiment homework: [specify]
Cognitive restructuring homework: [specify]
Exposure therapy homework: [specify]
Journaling homework: [specify]
Self monitoring homework: [specify] [/textarea]

sleep hygiene discussed including
[checklist name="variable_1" value="establishing regular relaxing bedtime routine|exposure to sunlight during day, as well as darkness at night|limiting screen time before going to bed|exercise during day|impact of substance use on sleep"]
discussed ways to better manage finances:
[checkbox name="variable_1" value="have spending plan or budget|track monthly spending|prioritizing spending on groceries, personal care items"]
education provided
[checkbox name="variable_1" value="re: health benefits of socialization & ways to improve socialization including forcing self to go out even when don't want|to practice conversation starters|option B|option C"]
nutrition discussed including
[checkbox name="variable_1" value="role of nutrition in mental well-being|heart healthy diet|importance of including variety of fruits & vegetables|limiting or eliminating processed food & sweetened beverages"]

[checkbox name="variable_1" value="Demonstrated Active Listening Skills"]

[checklist name="variable_1" value="Used Reflection, & Clarified Priorities & Readiness|Used Collaborative Approach To Agenda Map|
Identifying

[checklist name="variable_1" value="option A|option B|option C"]Used Open-Ended Questions To Assist In Exploring Problem Further, | Assessed Understanding & Previous Barriers. |Provided Affirmations & Built Confidence Through Ask-Tell-Ask, | Praise Given To Support
[textarea name="variable_1" default="Praise: Specify At Least 1 Positive Event, Attitude Or Strength Of Identified"]

[textarea name="variable_1" default="Resources Provided:"]

[checklist name="variable_1" value="Mi Worksheet- Agenda Mapping.|Mi Worksheet- Exploring Pros & Cons|Mi Worksheet- Change Plan|List Of Community Resources For |Referral To |Phone Numbers For "]
[textarea name="variable_1" default="Specific Resources, Resources Not Listed, Or Indicate None"]

[checklist name="Interventions"
Asked open ended questions|utilized reflective listening|conducted mental status exam|provided psychoeducation around|modeled technique|used exercise|Used motivational interviewing to increase motivation around"]

[textarea name="variable_1" default=""]
[checklist name="variable_1"
behavior modification|cbt |choice making |client centered|communication skills |coping skills |crisis |crisis intervention|dbt|family/couples |flat |grief work |hallucinations |limit setting |mindfulness |motivational interviewing |parenting skills |positive reinforcement |problem solving |psychoeducation |rapport building |reality testing |redirection |reframing |relaxation training |role playing |stress reduction |structural family therapy |support linking |supportive interaction |telephone call|solution focused |support linking|supportive therapy|coping skills|validation| centered "]

[checklist name="to"
In Order to...
|Reduce sx of
|help articulate feelings about
|encourage to share thoughts around
|help make plan around"]

Intervention details/Other Therapeutic Interventions Provided:
Reviewed current and past functioning
Developed treatment plan
Assessed risk of harm
Contracted for safety
Discussed barriers to progress
Introduced parenting strategies
Evaluated progress toward treatment goals.
Provided [link url="https://www.soapnote.org" memo="referral or linkage"]
Provided
[link url="https://www.soapnote.org" memo="Education and Information "]
Discussed alternative behaviors
Current Psychotherapy
Focus Of Psychotherapy:
Modality:
Prior tx:
VERBS
COMMON
Active Listening/Rapport Building
Exploration of
Psychoeducation
MICBT
BEHAVIORALMINDFULNESS/COPING SKILLSINTERPERSONALPROBLEM SOLVING

Psycho-Social Interventions:Measurable Objectives Include:
Work onPsychotherapy Homework

sleep hygiene discussed including

discussed ways to better manage finances:

education provided

nutrition discussed including




Used Open-Ended Questions To Assist In Exploring Problem Further, | Assessed Understanding & Previous Barriers. |Provided Affirmations & Built Confidence Through Ask-Tell-Ask, | Praise Given To Support














Intervention details/Other Therapeutic Interventions Provided:
Reviewed current and past functioning
Developed treatment plan
Assessed risk of harm
Contracted for safety
Discussed barriers to progress
Introduced parenting strategies
Evaluated progress toward treatment goals.
Provided referral or linkage
Provided
Education and Information
Discussed alternative behaviors

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