MBP 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="MHCP|EDTP|Private"]
Location: The Mind Body Practice - Bella Vista; [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="."]

Current Weight (for clients with hx of ED only): [text name="WEIGHT" default="-"] 
[textarea name="grams" default=""]

MSE
Appearance: [text name="CLIENTNAME" default="Name"] presents with an appearance [select value="befitting|exceeding|falling short of"] their stated years, is of [select value="an average|a slender|a petite|a robust|tall"] stature and appears to be [select value="proportionate in weight|somewhat corpulent|somewhat gaunt|noticeably portly|distinctly undernourished"] relative to the build. [text name="CLIENTNAME" default="Name"]'s grooming, hygiene, and self-care exhibit a standard that appears to be [checkbox value="befitting of social norms|somewhat neglected|remarkably meticulous"]. [text name="CLIENTNAME" default="Name"]'s attire is [checkbox name="attire" value="neat, clean, casual, and suitable for the occasion|clean, though unremarkable|unseemly for their age|incongruent with the occasion|exceedingly meticulous|disordered|sullied|eccentric|malodourous|slightly inappropriate for weather"].    
Engagement: [checkbox name="variable_11" value="No significant concerns|Calm and cooperative|Ease of separation from parent|Defiant|Overfamiliar| Appeared eager to please clinician"]
Mood and Affect: Mood was reported to be [checkbox name="variable_2" value="neutral|euthymic|anxious|depressed|flat|anxious|depressed|angry|agitated|frustrated|grieving"] which appeared [select name="variable_3" value="congruent|incongruent"] with observed affect.
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 legs|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|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|Acceptable"] 
Judgment: [checkbox name="variable_13" value="Good|Improving|Limited|Acceptable"] 

Risk Assessment
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/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: The Mind Body Practice - Bella Vista;
Present: Faith;

Current Weight (for clients with hx of ED only):


MSE
Appearance: presents with an appearance their stated years, is of stature and appears to be relative to the build. 's grooming, hygiene, and self-care exhibit a standard that appears to be . 's attire is .
Engagement:
Mood and Affect: Mood was reported to be which appeared with observed affect.
Posture and Movement:
Speech:
Behaviour:
Eye Contact:
Thought Content:
Cognition/Memory:
Perception:
Insight:
Judgment:

Risk Assessment
Suicide:
Self-harm:
Risk to Children/Others:

Discussed in session:


Interventions Provided:


Homework:


Treatment plan for next session:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.71, 38 form elements, 113 boilerplate words, 7 text boxes, 4 text areas, 1 dates, 19 checkboxes, 7 drop downs, 203 total clicks
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