2024 Faith – CBT/CBT-E/DBT Session Note (Final)

Treatment Session [text name="treatmentsession" default="5 or 9?"]
Clinician: Faith San Diego (Clinical Psychology Registrar)
Date: [date name="date" date="01-11-2024"]
Referral Type: [checkbox name="referral" value="MHTP|EDTP|Private"]
Location: [checkbox name="location" value="In-Person|Telehealth|Phone Consultation"]
Present: Faith; [checkbox name="present" value=""] [text name="Name" default=";"][checkbox name="present" value="Mother|Father"] [text name="parentname" default="."]

MSE
Appearance: [text name="APPEARANCE" default=""] [text name="CLIENTNAME" default="Name"]'s grooming, hygiene, and self-care exhibit a standard that appears to be [checkbox value="acceptable|somewhat neglected"]. [text name="CLIENTNAME" default="Name"]'s attire is [checkbox name="attire" value="neat, clean, casual, and suitable for the occasion|acceptable|inappropriate for setting"].    
Engagement: [checkbox name="variable_11" value="No significant concerns|Cooperative|Defiant|Overfamiliar| Appeared too eager to please clinician"]
Mood: Mood was reported to be [checkbox name="variable_2" value="neutral|euthymic|anxious|depressed|flat|anxious|depressed|angry|agitated|frustrated|grieving"] 
Affect: [textarea name="variable_25" default=""] which appeared [select name="variable_3" value="congruent|incongruent"] with  reported mood
Posture and Movement: [checkbox name="variable_4" value="No significant concerns|Relaxed|Restless|Tense|Aggressive |Slumped|Psychomotor slowing observed|Psychomotor agitation observed|Exhbited odd mannerisms| Erratic|Bouncing leg/s|fidgeting with toy"]
Speech: [checkbox name="variable_5" value="Normal rate, tone & volume|Loud|Quiet|Hurried|Forced|Verbose|Rambling|Pressured|Presented with a speech impediment"]
Behaviour: [checkbox name="variable_6" value="No significant concerns|Tired/fatigued|Distant| Crying| Cautious| Yawning| Depressed|Anxious|Agitated"]
Eye Contact: [checkbox name="variable_7" value="No significant concerns| Fair|Avoidant"]
Thought Content: [checkbox name="variable_8" value="No significant concerns|Goal-oriented|Past-oriented|Tangential|Rapid-fire|Delusions  present|Obsessive|Preoccupied"]
Cognition/Memory: [checkbox name="variable_9" value="No significant concerns|Intact|Demonstrated some difficulties|Impaired"]
Perception: [checkbox name="variable_10" value="No significant concerns|Presence of hallucinatory behaviours evident"]
Insight: [checkbox name="variable_12" value="Good|Improving|Limited|Fair"] 
Judgment: [checkbox name="variable_13" value="Good|Improving|Limited|Fair"] 
Client's reliability to report: [checkbox name="variable_14" value="Reliable reporter|Difficult to ascertain   reliability|Fickle|Unreliable"] 

Risk Assessment
- Current Risk Status: low/high/similar relative to most drug  and    alcohol patients
- Current Risk State: low/high/at baseline relative to self
Suicide: [select name="variable_14" value="denied any thoughts of suicide, intent, plans or access to means|voiced indistinct thoughts of ending their life, albeit with no serious intent|shared intense thoughts of suicide lacking in serious intent| conveyed thoughts of suicide, inclusive of a plan, but lacking a resolute intent|expressed a potent intent to commit suicide, but without a specified plan| unveiled a determined intent and a devised plan for suicide| expressed an immediate crisis of suicidal urgency and a need not to be left unattended| at baseline"].
Self-harm: [select name="variable_15" value="denied any thoughts of DSH, intent, plans or access to means|revealed occasional thoughts of self-harm without suicidal ideation|confessed to sporadic self-harm thoughts accompanied by suicidal ideation, yet without definitive plans or earnest intent|reported engaging in non-suicidal self-injury| at baseline"]
Risk to Children
Risk to Others: [select name="variable_16" value="denied any thoughts of harming others/children, intent, plans or access to means|admitted to thoughts of harming others but without intent"]

Discussed in session:
[textarea name="discussion" default=""]

Interventions Provided:
[checkbox name="intervention" value="Discussed DBT-informed diary card information|Socratic questioning|Supportive counselling|Psychoeducation|Parent psychoeducation| Challenging thoughts| Cognitive Restructuring/Reframing|Relaxation and stress reduction|Exposure|Goal setting|Decisional balance|Relapse prevention|Activity scheduling and behaviour activation|Problem solving|Behavioural experiment|Role Playing|Identifying mind states: emotion, reasonable, wise|What skills: observe, describe, participate |How skills: non-judgmentally, focused, effective| Dialectics: identifying extremes, finding middle ground |Distract (ACCEPTS) |Pros and Cons |Urge Surfing |Self Soothe with 5 senses |Improve the moment |Radical acceptance|Identifying goals and barriers |Healthy boundaries |Identifying and challenging myths about interpersonal effectiveness |DEARMAN |GIVE |FAST |Repair relationship (plan and deliver apology) |Observing and Describing emotions |Identify function of emotions |Identify primary and secondary emotions |Opposite action |Taking care of emotions |Look after self (PLEASE) |Problem Solving |Live according to values |Build mastery |Accumulating positive emotions |Mindfulness for positive emotions "]

Homework:
[textarea name="variable_19" default=""]

Treatment plan for next session:
[checkbox name="treatmentplan" value="DBT-informed diary card|Socratic questioning|Supportive counselling|Psychoeducation|Parent psychoeducation| Challenging thoughts| Cognitive Restructuring/Reframing|Relaxation and stress reduction|Exposure|Goal setting|Decisional balance|Relapse prevention|Activity scheduling and behaviour activation|Problem solving|Behavioural experiment|Psychoeducation|Role Playing|Identifying mind states: emotion, reasonable, wise|What skills: observe, describe, participate |How skills: non-judgmentally, focused, effective| Dialectics: identifying extremes, finding middle ground |Distract (ACCEPTS) |Pros and Cons |Urge Surfing|TIP    |Self Soothe with 5 senses |Improve the moment |Radical acceptance|Identifying goals and barriers |Healthy boundaries |Identifying and challenging myths about interpersonal effectiveness |DEARMAN |GIVE |FAST |Repair relationship (plan and deliver apology) |Observing and Describing emotions |Identify function of emotions |Identify primary and secondary emotions |Opposite action |Taking care of emotions |Look after self (PLEASE) |Problem Solving |Live according to values |Build mastery |Accumulating positive emotions |Mindfulness for positive emotions"]
[textarea name="target" default=""]
Treatment Session
Clinician: Faith San Diego (Clinical Psychology Registrar)
Date:
Referral Type:
Location:
Present: Faith;

MSE
Appearance: 's grooming, hygiene, and self-care exhibit a standard that appears to be . 's attire is .
Engagement:
Mood: Mood was reported to be
Affect:
which appeared with reported mood
Posture and Movement:
Speech:
Behaviour:
Eye Contact:
Thought Content:
Cognition/Memory:
Perception:
Insight:
Judgment:
Client's reliability to report:

Risk Assessment
- Current Risk Status: low/high/similar relative to most drug and alcohol patients
- Current Risk State: low/high/at baseline relative to self
Suicide: .
Self-harm:
Risk to Children
Risk to Others:

Discussed in session:


Interventions Provided:


Homework:


Treatment plan for next session:

Result - Copy and paste this output:

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