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
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