Counseling Progress Note 1

Client Name or ID:[text name="Name"]
Session Date:[date name="Date"]
Length of session in minutes:[text name="Minutes" default="50"]
Session format: [select name="Format" value="individual, in person|group, in person|individual, Telehealth|group, Telehealth"]

Presentation
Client's general presentation was [select name="general" value="alert and oriented.|obtunded.|disoriented.|"] Appearance was [select name="grooming" value="well kempt|poorly kempt"], and client was [select name="dress" value="appropriately|inappropriately"] dressed, with [select name="hygiene" value="appropriate|poor"] hygiene.  Client appeared to be [select name="appearance" value="calm and in no acute distress|agitated and in acute psychological distress|"]. They were [select name="interaction" value="interactive|cooperative|hyperverbose|guarded|defensive|withdrawn|hostile|fearful|anxious|uncooperative"] and [select name="characteristic" value="cooperative|hyperverbose|guarded|defensive|withdrawn|hostile|fearful|anxious|uncooperative"] with others in the environment. Client maintained [select name="eye" value="good|fair|poor"] eye contact.

Client's activity level was [select name="activity" value="in the normal range|in the overactive range|characterized by impulsiveness|agitated|lethargic|not able to be assessed|"]. Thought process was [select name="thought" value="oriented and normal|disorganized|tangential|preoccupied and/or obsessive|characterized by paucity of ideas|displayed instances of thought blocking|circumstantial"].  The client's mood was [select name="mood" value="neutral|happy|depressed|dysphoric|anxious|angry|irritable|euphoric|hypomanic|playful|hostile|fearful|sad"] which was [select name="congruent" value="congruent|incongruent"] with their [select name="affect" value="broad and reactive|constricted|blunted|flat|dysregulated|inappropriate"] affect.  Speech was [checkbox name="speech" value="normal|atypically slow|atypically fast|loud|soft|monotone|impaired|unintelligible|unable to be assessed because client was non-responsive"].  Ability to focus and pay attention was [select name="focus" value="developmentally appropriate|limited|impaired|severely impaired"] and frustration tolerance was [select name="frustration" value="developmentally appropriate|limited|impaired|severely impaired"].
[comment memo="Additional Comments:"]
[textarea default=""]

Safety and Medical Issues
The client [select name="safety" value="denies safety issues.|disclosed"][conditional field="safety" condition="(safety).is('disclosed')"] [checkbox name="issue" value="suicidal ideation|non-suicidal self injury|homicidal ideation|abuse or neglect|safety concerns"].  Mandated reporting [select name="report" value="was|was not"] required by law and/or Hays CISD policy. Risk assessment and additional documentation required by HCISD and/or the law was completed.  Mandated report completed on 
[date name="report_date"].
[textarea name="variable_1" default="more information"]
[/conditional]
The client[select name="medical" value="denies|disclosed"] medical issues of concern.
[textarea default=""]