MH Follow up Note (Jessica)

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)-40"] 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]
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[checkbox name="extended_reasons" value="Medical necessity-factors influencing length and/or frequency of sessions include rapport building with client|to address new symptoms or re-emergence of old symptoms|assessment and stabilization|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]
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Modality/Type of Contact: [checkbox name="Mode" value="Individual|Family|Group|Collateral"].[text]
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[checkbox name="Attendees" value="Seen with:|mother|father|siblings|significant other|parent|guardian|family member|grandparent|foster parent|case worker"].[text]
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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]
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Patient states: [text] [checkbox name="variable_1" value="Concerns include depression|anxiety|panic|ADHD|PTSD|OCD|bipolar disorder|insomnia|psychosis|alcohol use|personality disorder|opioid use|neurocognitive concerns|recent life changes|recent significant loss|recent trauma"].History of Presenting Illness:
[checkbox name="depression" memo="depression" value=""][checkbox name="anxiety" memo="anxiety" value=""][checkbox name="panic" memo="panic" value=""][checkbox name="ADHD" memo="ADHD" value=""][checkbox name="PTSD" memo="PTSD" value=""][checkbox name="OCD" memo="OCD" value=""][checkbox name="bipolar" memo="bipolar disorder" value=""][checkbox name="insomnia" memo="insomnia" value=""][checkbox name="psychosis" memo="psychosis" value=""][checkbox name="alcohol" memo="alcohol" value=""][checkbox name="opioid" memo="opioid" value=""][checkbox name="personality" memo="personality" value=""][checkbox name="neuro" memo="neurocognitive" value=""]
[conditional field="depression" condition="(depression).is('')"]
Depression is reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|little interest or pleasure in doing things|hopelessness|helplessness|sleeping too much|difficulty getting to sleep|difficulty staying asleep|feeling tired or having little energy|poor appetite|overeating|feelings of inadequacy|irritability|poor concentration|psychomotor retardation|psychomotor agitation|suicidal ideation"]. There are no reports of [checkbox value="little interest or pleasure in doing things|hopelessness|helplessness|sleeping too much|difficulty getting to sleep|difficulty staying asleep|feeling tired or having little energy|poor appetite|overeating|feelings of inadequacy|irritability|poor concentration|psychomotor retardation|psychomotor agitation|suicidal ideation"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="anxiety" condition="(anxiety).is('')"]
Anxiety is reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|feeling restless/wound up|fatigue|difficulty concentrating|irritability|difficulty falling to sleep|difficulty staying asleep|feeling tired or having little energy|muscle tension|headaches|feeling overwhelmed|irritability|poor concentration|restlessness|loss of appetite"]. There are no reports of [checkbox value="feeling restless/wound up|fatigue|difficulty concentrating|irritability|difficulty falling to sleep|difficulty staying asleep|feeling tired or having little energy|muscle tension|headaches|feeling overwhelmed|irritability|poor concentration|restlessness|loss of appetite"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="panic" condition="(panic).is('')"]
Panic symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|palpitations/racing heart|sweating|shaking|shortness of breath|chest pain/tightness|nausea/stomach cramps|numbness/tingling|fear of losing control|closed in feeling|feeling overwhelmed|heat sensations|chills|trembling/shaking"]. There are no reports of [checkbox value="palpitations/racing heart|sweating|shaking|shortness of breath|chest pain/tightness|nausea/stomach cramps|numbness/tingling|fear of losing control|closed in feeling|feeling overwhelmed|heat sensations|chills|trembling/shaking"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="ADHD" condition="(ADHD).is('')"]
ADHD symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|inattention|careless mistakes|difficulty sustaining attention|problems following conversations|easily side tracked|difficulty organizing tasks/activities|avoidance and procrastination|forgetfulness|easily distracted by unrelated thoughts|fidgeting|inability to relax|excessive talking|difficulty waiting/reduced patience"]. There are no reports of [checkbox value="inattention|careless mistakes|difficulty sustaining attention|problems following conversations|easily side tracked|difficulty organizing tasks/activities|avoidance and procrastination|forgetfulness|easily distracted by unrelated thoughts|fidgeting|inability to relax|excessive talking|difficulty waiting/reduced patience"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="PTSD" condition="(PTSD).is('')"]
PTSD symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|nightmares|flashbacks|intrusive memories/thoughts|avoidance|negative affect|loss of interest|isolation|difficulty experiencing positive emotions|irritability|annoyance|risky/self destructive behaviors|hypervigilance|heightened startle reaction|difficulty concentrating|difficulty falling asleep|difficulty staying asleep"]. There are no reports of [checkbox value="nightmares|flashbacks|intrusive memories/thoughts|avoidance|negative affect|loss of interest|isolation|difficulty experiencing positive emotions|irritability|annoyance|risky/self destructive behaviors|hypervigilance|heightened startle reaction|difficulty concentrating|difficulty falling asleep|difficulty staying asleep"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="OCD" condition="(OCD).is('')"]
OCD symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|recurring thoughts|recurring images|recurring urges|urge to neutralize thoughts|repetitive behaviors|counting|focusing on geometry|checking|isolation|organizing/aligning objects|hoarding|fear of germs/illness|blinking|touching/tapping|needing constant reassurance|fear of dread|mental rituals|excessive time spent thinking or engaging in compulsive behavior"]. There are no reports of [checkbox value="recurring thoughts|recurring images|recurring urges|urge to neutralize thoughts|repetitive behaviors|counting|focusing on geometry|checking|isolation|organizing/aligning objects|hoarding|fear of germs/illness|blinking|touching/tapping|needing constant reassurance|fear of dread|mental rituals|excessive time spent thinking or engaging in compulsive behavior"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="bipolar" condition="(bipolar).is('')"]
Bipolar symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|elevated mood|irritable mood|increased self esteem|loss of sleep|racing thoughts|difficulty keeping up with thoughts|increased desire to speak|feeling more distracted|feeling more energetic|increased desire to engage in activities|agitation|impulsive behaviors|feeling more social/outgoing|increased sex drive|spending money|using drugs/alcohol"]. There are no reports of [checkbox value="elevated mood|irritable mood|increased self esteem|loss of sleep|racing thoughts|difficulty keeping up with thoughts|increased desire to speak|feeling more distracted|feeling more energetic|increased desire to engage in activities|agitation|impulsive behaviors|feeling more social/outgoing|increased sex drive|spending money|using drugs/alcohol"][textarea memo="Additional information" rows="1"][/conditional]
[conditional field="insomnia" condition="(insomnia).is('')"]
Insomnia symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|difficulty falling asleep|difficulty staying asleep|early morning awakening|nightmares|vivid dreams|thrashing in sleep|sleep walking|daytime sedation/fatigue|sleep talking|night terrors|confusion|sleep related eating|hallucinations going to sleep|hallucinations when taking up"]. There are no reports of [checkbox value="difficulty falling asleep|difficulty staying asleep|early morning awakening|nightmares|vivid dreams|thrashing in sleep|sleep walking|daytime sedation/fatigue|sleep talking|night terrors|confusion|sleep related eating|hallucinations going to sleep|hallucinations when taking up"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="psychosis" condition="(psychosis).is('')"]
Psychotic symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|delusions of persecution|jealous delusions|somatic delusions|grandiose delusions|religious delusions|thought broadcasting|thought insertion|auditory hallucinations|visual hallucinations|disorganized thoughts|disorganized behaviors|confusion|social isolation|loss of motivation|problems focusing|suicidal thoughts|anxiety"]. There are no reports of [checkbox value="delusions of persecution|jealous delusions|somatic delusions|grandiose delusions|religious delusions|thought broadcasting|thought insertion|auditory hallucinations|visual hallucinations|disorganized thoughts|disorganized behaviors|confusion|social isolation|loss of motivation|problems focusing|suicidal thoughts|anxiety"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="neuro" condition="(neuro).is('')"]
Cognitive symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|difficulty with complex attention|poor executive functioning|difficulty with short term memory|difficulty with long term memory|motor difficulties|confusion|repetitive behaviors|misplacing objects|difficulty understanding context|difficulty formulating speech|forgetting names/words|loss of interest|confusion|social isolation|loss of motivation|paranoia|visual hallucinations|auditory hallucinations|obsessive behaviors|hoarding behaviors|tremors|night terrors|sleeping during the day|not sleeping at night|agitation|threatening behaviors|inappropriate behaviors"]. There are no reports of [checkbox value="difficulty with complex attention|poor executive functioning|difficulty with short term memory|difficulty with long term memory|motor difficulties|confusion|repetitive behaviors|misplacing objects|difficulty understanding context|difficulty formulating speech|forgetting names/words|loss of interest|confusion|social isolation|loss of motivation|paranoia|visual hallucinations|auditory hallucinations|obsessive behaviors|hoarding behaviors|tremors|night terrors|sleeping during the day|not sleeping at night|agitation|threatening behaviors|inappropriate behaviors"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="alcohol" condition="(alcohol).is('')"]
Alcohol use symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of alcohol use|daily drinking|drinking more than anticipated|inability to cut down on drinking|cravings to drink|blackouts|hangovers|urges to drink|missing work due to drinking|drinking alone|drinking and driving|drinking to fall asleep|escalating alcohol use|tremors|nausea|vomiting|headaches|sweating|anxiety|racing heart|confusion|visual hallucinations|auditory hallucinations|seizures"]. There are no reports of [checkbox value="daily drinking|drinking more than anticipated|inability to cut down on drinking|cravings to drink|blackouts|hangovers|urges to drink|missing work|drinking alone|drinking and driving|drinking to fall asleep|needing to drink more to get the same effect|tremors|nausea|sweating|palpitations|confusion|visual hallucinations|auditory hallucinations|seizures"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="opioid" condition="(opioid).is('')"]
Opioid use symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms of opioid use|cravings|urges to use opioids|continued opioid use|use of fentanyl|recent overdose|drowsiness|dizziness|fainting|fatigue|chest pain|difficulty breathing|missing work|irritability|pinpoint pupils|nausea|vomiting|loss of appetite|constipation|diarrhea|stomach cramping|weight loss|racing heart|sweating|chills|palpitations|tearing eyes|yawning|insomnia|bone pain|goose bumps|tremors|leg swelling|yellowing of eyes|loss of libido|confusion|visual hallucinations|auditory hallucinations"]. There are no reports of [checkbox value="no concerning progression of symptoms of opioid use|cravings|urges to use opioids|continued opioid use|use of fentanyl|recent overdose|drowsiness|dizziness|fainting|fatigue|chest pain|difficulty breathing|missing work|irritability|pinpoint pupils|nausea|vomiting|loss of appetite|constipation|diarrhea|stomach cramping|weight loss|racing heart|sweating|chills|palpitations|tearing eyes|yawning|insomnia|bone pain|goose bumps|tremors|leg swelling|yellowing of eyes|loss of libido|confusion|visual hallucinations|auditory hallucinations"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="personality" condition="(personality).is('')"]
Personality symptoms are [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression interpersonal relationships, impulsivity, behavioral regulation, or affect regulation|unstable relationships with others|idealizing and devaluing|identity disturbance|feelings of emptiness|affective lability|excessive anger|aggression|efforts to avoid abandonment|impulsive behaviors|suicidality|self injurious behavior|thrill seeking|paranoia|dissociation|attention seeking"]. There are no reports of [checkbox value="no concerning progression interpersonal relationships, impulsivity, behavioral regulation, or affect regulation|unstable relationships with others|idealizing and devaluing|identity disturbance|feelings of emptiness|affective lability|excessive anger|aggression|efforts to avoid abandonment|impulsive behaviors|suicidality|self injurious behavior|thrill seeking|paranoia|dissociation|attention seeking"].[textarea memo="Additional information" rows="1"][/conditional]
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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]
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Impact of Symptoms on Functional Status
--Relational: [select name="Rel" value="Low|Moderate|High"]
[text]
--Occupational/School: [select name="Occ_Edu" value="Low|Moderate|High"]
[text]
--Physical: [select name="Phy" value="Low|Moderate|High"]
[text]
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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]
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[checkbox name="variable_8" value="We focused on empathetic validation, reassurance, and further exploring and naming emotions/experiences with the purpose of enhancing ego function, supporting mature defenses, and fostering insight into psychosocial stressors.|The patient I worked on cognitive restructuring by challenging automatic negative thoughts that contribute to depression and anxiety, and identified cognitive distortions also influencing mood. |We reviewed the relationship between thoughts, feelings, and behaviors, and considered how to address ones feelings by modifying the other two constructs.|The patient I worked on emotional experiencing and processing of feelings that arise around certain stressors or events, that historically are pushed down, buried, or otherwise repressed. We considered the pitfalls of emotional avoidance including the onset or worsening of depression and anxiety.|The patient and I explored the patients stressors and frustrations. I validated these frustrations and
empathized with the experience. We did explore some ways to improve distress/frustration tolerance, including healthy distraction (with pleasurable activities, focusing on others, counting, and tasks/chores), radical acceptance, self-soothing techniques, mindfulness, coping thoughts, and self- affirming thoughts.|We explored her fear of abandonment which is chronic and longstanding and how the fear of abandonment does not make healthy decisions whereas the logical and more thoughtful does, and we want to recognize who is making decisions for her at different times as a way of developing cognitive dissonance from the thoughts, impulses, and decisions that her fear of abandonment self makes.|We explored tendencies towards perfectionism, and how this inherently implies a binary way of thinking, in which one has either been perfect or failed. We considered the inauthenticity of this thinking and how there is a spectrum between these points. We further considered how people make opinions of us based upon a number of interactions or data points such that an average is taken and the opinion is based upon this. Accordingly, one can have several positive data points which allows room to make some mistakes or have negative data points without drastically distorting the perception of us.|We worked on problematic reactions used to deal with extremely intense emotions and increasing understanding of what leads to problematic behaviors or responses to these emotions.|We worked on relationship issues such as interpersonal conflict, role transitions, or grief that may contribute to the development or continuation of mental health problems or symptoms.|We worked on unconscious influences and feelings that may be related to past events and interactions which allows for better self awareness, change, and recovery.
|Grief related to the loss of a loved one or relationship."] Addressing these psychological components should increase the response rate or at least mitigate symptoms, decreasing the risk for decompensation of underlying illness or the need for additional interventions or medications.Assessment:
[textarea cols=10 rows=1] presents with [checkbox name="variable_40" value="stable mood symptoms with no worsening behaviors, symptom progression, or side effects of the medication regimen."] [checkbox name="variable_41" value="I am not noting any clinical signs to suggest the patient is at an imminent risk in the foreseeable future."] [checkbox name="variable_43" value="Given the sustained symptom improvement and subjective satisfaction with symptom control, no modifications to the current medical treatment is indicated."] [checkbox name="variable_44" value="inadequate response to medications with residual mood symptoms."] [checkbox name="variable_45" value="I will adjust the medications to account for the change in clinical picture."] [checkbox name="variable_46" value="The patient will reach out to me should any symptoms worsen or if the clinical picture changes."] [textarea memo="Additional information" rows="1"]
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[checkbox name="Interventions" value="Primary Clinical Interventions and Strategies Implemented: |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 restructuring|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|clarify diagnosis|clinical diagnostic assessment"].[text]
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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]
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Response to Intervention: [checkbox name="RTI" value="Minimal|Problematic|Adequate|Moderate|Excellent|Engaged in the therapeutic process"].[text]
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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|Review Safety Plan"]. [text]
[text]
Jessica Dorner, LPC
Mental Health Therapist