Expandable Note for 1:1 Therapy Jessica’s Version

SUBJECTIVE
[text name="first_name" default="Client"] arrived [select name="on_time" value="on time|5-10 minutes late| more than 10 minutes late|xxxxxx"] for [select name="scheduled_crisis" value="scheduled follow up|crisis|xxxxxx"] session. This session is[select name="placeofservice" cols="40"    value=" via live  telehealth with the client at their home in WI.| via live telehealth with the client confirmed to be in WI.| in person."] Obtained consent to treat using this modality. This session was medically necessary to address symptoms, improve functioning [checkbox name="preventdecomp" value=" prevent decompensation"][checkbox name="reducesx" value=" reduce symptoms"][checkbox name="maintprogr" value=" maintain progress"][checkbox name="prevhighterneed" value=" prevent necessity for higher level of care"]. [checkbox name="Extended" value=" "][comment memo="Extended Session Length"][conditional field="Extended" condition="(Extended).is(' ')"] * Factors influencing length and/or frequency of sessions include: clinical symptoms cause functional impairment in ability to complete activities of daily living, occupational functioning, and/or social functioning that is not characteristic with the person is not symptomatic [checkbox name="extended_reasons" value="time needed to address and contain intense issues|client presents with multiple life stressors|symptoms are impacting multiple domains of life (Relationships, work, school community)|client trauma history exploration|significant trauma history necessitates additional time for disclosure and containment|grounding needed for symptoms that emerged during session|addressing complicated issues related to diagnosis and clinical presentation|addressing new or emergent symptoms|client reports subjective level of distress|client reports subjective level of acute issues|assessment and stabilization|client crisis|client presenting with acute issues|client at risk of inpatient treatment or ED admissions due to possibility of decompensation without the current level of care|current level of treatment is necessary as the client continues to meet diagnostic criteria and identifies symptoms that impair functioning. Without continued care at this level the client may deteriorate, be unable to maintain improvements or continue to make gains|client requested longer session due to decreased frequency of sessions|utilizing exposure therapy for ptsd, panic disorder, OCD or specific phobia|parental involvement for psychoeducation or emotional management skills|limited health support network|client is unable to share content with others in support system due to nature of topic|IFS protocol being utilized|bi-weekly sessions|monthly sessions to maintain acquired skills"]. [text name="extendedlengthtext" default=" " size="75"][/conditional]
[var name="first_name"] [textarea name="presentation_text" default=" presents as calm and cooperative, with casual dress, normal grooming and hygiene." rows="2"] [var name="first_name"] reports experiencing [checkbox name="concerns" value="depression|sadness|anxiety|anger|distress|recent panic episodes|sleep disturbance|obsessive thoughts/compulsions|mood swings|visual hallucinations|auditory hallucinations|neurocognitive changes|recent trauma|difficulty managing emotional reactions|interpersonal or family conflict|related to "][textarea name="rxdto" default="" rows="1"]. [checkbox name="expand_med" value="" memo="Meds"][conditional field="expand_med" condition="(expand_med).is('')"][checkbox value="Client reports adherence with all medications. |Client reports non-adherence with some medications.| Client reports compliance with psychotropic medications. |Client reports non-adherence with psychotropic medications. "][/conditional][checkbox name="expand_sub" value="" memo="Substance Use"][conditional field="expand_sub" condition="(expand_sub).is('')"][checkbox value="Client reports continued abstinence. |Client reports continued from primary substance. |Client endorses recent alcohol use. |Client endorses recent mehtamphetamine use. |Client endorses recent cocaine use. |Client endorses recent cannabis use. |Client endorses recent use of sedative/hypnotics. |Client endorses recent substance use. "][/conditional][comment memo="Additional client quotes, stressors, relationship, financial, medical, legal, etc."][textarea name="SubExt" default=" " rows="2"]
OBJECTIVE
Affect: [checkbox name="affect" value="normal range|distressed|tearful|labile|detached|flat|agitated|shallow|tired"].    
Mood: [checkbox name="mood" value="euthymic|dysthymic|anxious|depressed|elevated|irritable|expansive|hostile|congruent with content|incongruent with content"].    
Thought process:    [checkbox name="tproc1" value=" goal-directed and logical|disorganized|tangential|future-oriented|past-oriented"].    
Thought content:    [checkbox name="tcont1" value=" within normal limits|features paranoid ideation|features auditory hallucinations|features visual hallucintations|features delusions|features low self-image|features ideas of reference|features obsessions"].    
[checkbox value="No evidence or report of SI/HI. "]
[comment memo="Interventions & Response"]
[checkbox name="expand_safety" value="" memo="SI/HI Risk"][conditional field="expand_safety" condition="(expand_safety).is('')"][checkbox name="Safety" value="Client disclosed current safety concerns|Client denied suicidal ideation|Client reported passive suicidal ideation|Client reported active suicidal ideation|Client reported passive homicidal ideation|Client reported active homicidal ideation|denies plan/method/intention|has a plan|denies method/intention|has intent to follow through with plan|has means to follow through with plan|higher level of care is needed|urgent assessment for higher level of care is needed|client participated in safety planning|support person participated in risk reduction and safety planning|client unwilling/unable to participate in safety planning|clinician to complete mandated report to appropriate agency"]. [/conditional][checkbox name="expand_basic" value="" memo="Basic"][conditional field="expand_basic" condition="(expand_basic).is('')"]
[checkbox name="bas0" value="Thpst delivered evidence based therapuetic techniques and interventions, including "][checkbox value="active listening|assessment|rapport building|CBT|challenging cognitions|cognitive    challenging|cognitive refocusing|communication    skills|coping skills|DBT|EMDR|exploration of relational patterns|exploration of family of origin relational patterns|exploration of trauma|exploration of emotions|exploration of meaning|exploration of purpose|exploration of values|goal setting|guided imagery|IFS|parts work|identification of triggers|mindfulness|parenting skills|problem solving|psycho-education|somatic exercises|supportive    reflection|validation"][comment memo="*"][checkbox name="bas8" value=", to address clients therapuetic goal "][textarea name="basgoal" default=". goal"    rows=2][comment memo="*"][checkbox name="bas9" value="Client's level of engagement was "][checkbox value="active|moderate|variable|inconsistent|uninvolved|withdrawn|passive|resistant|hostile"][checkbox name="bas14" value=", which is consistent with previous session engagement. "][checkbox name="bas15" value=", which is inconsistent with previous session engagement. "][/conditional] [checkbox name="expand_mi" value="" memo="MI"][conditional field="expand_mi" condition="(expand_mi).is('')"]
[checkbox name="mi0" value="Thpst delivered motivational interviewing techniques, including "][checkbox value="development of discrepancy|affirmations|summarizing|evoking change talk|collaborating with Client on a plan of action|avoiding argumentation|reflective listening"][checkbox name="mi8" value=", to influence Client’s stage of change. "][checkbox name="mi9" value="Ct’s stage of change is "][checkbox value="precontemplative|contemplative|preparation|action"][checkbox name="mi14" value=", which is maintained from previous session. "][checkbox name="mi15" value=", which is progress from previous session. "][/conditional][checkbox name="expand_cbt" value="" memo="CBT"][conditional field="expand_cbt" condition="(expand_cbt).is('')"][checkbox name="cbt1" value="Thpst described the interrelationship between thoughts, feelings and behavior, and how negative patterns form and impact mood and functioning over time. "][checkbox name="cbt2" value="Thpst guided Client in describing a recent event that activated distress. "][checkbox name="cbt3" value="Thpst provided Client with information related to cognitive distortions. "][checkbox name="cbt4" value="Thpst guided Client in identifying cognitive distortions that contribute to negative sxs. "][checkbox name="cbt5" value="Client was able to identify more realistic cognitions to replace the distortions and has committed to internalizing them. "][checkbox name="cbt6" value="Client receptive to Thpst challenging Client’s distorted beliefs and attitudes toward self and the event; was able to identify more realistic alternatives for these ideas. "][checkbox name="cbt7" value="Thpst encouraged Client to keep a mood log and any accompanying cognitive distortions associated with moods/emotions. "][checkbox name="cbt8" value="Thpst introduced and demonstrated use of a cognitive restructuring handout that allows Client to describe an activating event, associated feelings, identify cognitive distortions, and challenges Client to identify realistic alternative thoughts/beliefs to replace the distortions. "][checkbox name="cbt9" value="Client seemed receptive to the above interventions. "][checkbox name="cbt10" value="Client verbalized a commitment to practicing suggested tasks between sessions. "][/conditional][checkbox name="expand_depression" value="" memo="Beh Activation"][conditional field="expand_depression" condition="(expand_depression).is('')"] [checkbox value="Thpst guided Client in describing hx, severity and duration of depression symptoms and attempts by client to resolve it. "][checkbox value="Thpst reinforced acquired and natural adaptive coping methods, while highlighting those that seemed to have little or no effect. "][checkbox value="Thpst provided psychoeducation on behavioral activation, including the relationship between depression and motivation, and how even light activity can cultivate motivation. "][checkbox value="Thpst guided Client in identifying an activity that Client could commit to doing between sessions, and suggested that Ct observe what occurs with their sense of interest/motivation. "][checkbox value="Thpst guided Client in identifying activities that Client would be willing to commit to doing to enhance their behavioral activation practice. "][/conditional][checkbox name="expand_anx" value="" memo="Anxiety"][conditional field="expand_anx" condition="(expand_anx).is('')"][checkbox value="Thpst guided Client in describing hx, severity and duration of anxiety symptoms and attempts by client to resolve it. "][checkbox value="Thpst reinforced acquired and natural adaptive coping methods, while highlighting those that seemed to have little or no effect. "][checkbox name="anx0" value="Thpst prompted Client to explore and identify anxiety-related fears. "][checkbox name="anx1" value="Thpst prompted Ct to identify where in the body tension is felt and to describe the sensation. "][checkbox value="Thpst and Client discussed the role of substances in Client's coping style, and their perceived effectiveness. "][checkbox name="anx2" value="Thpst demonstrated and guided Client in practice of a deep-controlled breathing technique. "][checkbox name="anx3" value="Thpst demonstrated and guided Client in practice of a grounding technique describing present experiences that relate to the 5 senses. "][checkbox name="anx4" value="Thpst guided Client through progressive muscle relaxation technique. "][checkbox name="anx5" value="Thpst guided Ct through a guided meditation. "][checkbox name="anx6" value="Client rated anxiety level at a ___ and a ___ (0-10, 10 severe) before and after the intervention, respectively. "][checkbox name="anx7" value="Client seemed receptive to Thpst’s suggestion of practicing the intervention between sessions. "][/conditional][checkbox name="expand_meddx" value="" memo="New Medical dx"][conditional field="expand_meddx" condition="(expand_meddx).is('')"][checkbox value="Thpst engaged Client in discussion about recent medical dx. "][checkbox value="Thpst guided Client in exploring their emotions rx’d to recent dx. "][checkbox value="Client connected with and processed feelings of ___. "][checkbox value="Thpst and Client discussed societal and cultural stigma surrounding diagnosis and how it affects them. "][checkbox value="Thpst provided psychoeducation on diagnosis and treatment. "][checkbox value="Client demonstrated understanding of the information by engaging in discussion and asking appropriate questions. "][checkbox value="Thpst engaged Ct in identifying barriers to seeking medical care. "][checkbox value="Thpst utilized motivational interviewing techniques to develop discrepancy between life goals and HIV medication nonadherence. "][checkbox value="Thpst utilized Socratic questioning to explore Client’s resistance to engaging with primary medical provider. "][checkbox value="Thpst and Client collaborated on a plan to engage in primary care including  "][checkbox value="Thpst and Client explored aspects of wellness that contribute to better management of medical    condition, including nutrition, exercise, stress management, social support. "] [/conditional][checkbox name="expand_trauma" value="" memo="Narrative Exposure"][conditional field="expand_trauma" condition="(expand_trauma).is('')"][checkbox value="Thpst provided an overview of trauma exposure treatment, including safety and stability phase, exposure phase, and CBT phase. "][checkbox value="Thpst guided Client in learning how to scale anxiety/stress on a scale from 0-10 (10 severe), and engaged Client in a deep controlled breathing exercise. Client’s scores were __ and __ before and after the exercise, respectively.  "][checkbox value="Client participated in guided scaling and deep controlled breathing exercise at the beginning of the session, reporting anxiety scores of ___ and ___ before and after the exercise, respectively.  "][checkbox value="Thpst guided Client in imagining a box or container where the trauma content can be safely contained for the duration of treatment. Thpst suggested Client commit to not “unpacking” content between sessions. Thpst explained that this practice is meant to decrease intrusive thoughts and ruminations about the trauma. "][checkbox value="Thpst provided guidance in giving a chronological narrative of the trauma experience, e.g. describing memories the environment/surroundings, sensory experiences, and events that occurred with as much detail as possible. "][checkbox value="Thpst guided Client in creating a sketch of the environment to aid in giving the verbal narrative. " ][checkbox value="Thpst provided instruction on creating a written account of the trauma experience to aid in giving the verbal narrative; emphasizing on practicing safety and stability techniques learned in previous session both before and after writing. Thpst suggested that Client limit writing time to a period of no more than 45 minutes. "][checkbox value="Thpst engaged Client in providing a detailed verbal narrative of the trauma experience, pausing the narrative to process emotions as they surface. "][checkbox value="Client repeated the scaling and breathing exercises at the end of session, reporting scores of ___ and ___, respectively.  "][checkbox value="Client reported resolution of emotional activation that surfaced during the narrative exposure. "][checkbox value="Thpst engaged Client in exploring residual thoughts and beliefs that stem from the trauma experience.  "][checkbox value="With guidance from Thpst, Client was able to identify distortions and replace these cognitions with more realistic and factual statements.  "][checkbox value="Client committed to practice rehearsing the new statement as the old thought/belief arises.  "][checkbox value="Client reports enhanced ability to review the trauma content with decreased emotional arousal.  "][/conditional] [checkbox name="more_interventions" value="" memo="Misc"][conditional field="more_interventions" condition="(more_interventions).is('')"] [checkbox name="Misc" value="Interventions and strategies included: |Primary interventions and strategies included: |Additional intervention and strategies included: |rapport building|further assessment of|psychoeducation about primary diagnosis and symptoms|psychoeducation about ___|safety and stabilization and narrative exposure to trauma|demonstration and practice with mindfulness technique aimed at identify and move through emotional states without judgment|solution-focused brief therapy using Socratic questioning and reflective listening|reinforcement of learned adaptive coping skills|assertive communication skills| art therapy|play therapy|developing, communicating and enforcing appropriate boundaries|Tx plan review|role-play|modeling|expression through art|outlining a daily routine that addresses adequate sleep, nutrition, physical activity, social connection and pleasurable activities|development of better sleep hygiene habits|identifying personal core values|developing a list of problematic anger behaviors that can be eliminated incrementally, as well as alternative adaptive behaviors to replace them|in vitro exposure to memories/scenarios that activate social anxiety|techniques for the development of greater confidence and self-efficacy|development of social skills enhancement and practice through scripting and role-play|guided imagery used to develop/strengthen mindfulness skills|review of informed consent/confidentiality"].[/conditional] 
[textarea default="" rows="2"]
ASSESSMENT
[var name="first_name"] is currently displaying [select value="symptoms of |well managed |moderately managed |poorly managed "][checkbox value="depression|anxiety|sleep disturbance|psychosis|recent substance use|substance use disorder|mild|moderate|severe|in early remission|in sustained remission|PTSD|ADHD|gender dysphoria|cognitive impairment|impulsivity|mood lability"][textarea default=".    "    rows="2"]      
[var name="first_name"] has problems with affect/physiological regulation that are impacting their functioning in some life domains, but are able to control affect at times.
From the client’s report and therapist observation, [var name="first_name"] has functional impairment in the following areas:
[checkbox name="chk_som" value="Sense of meaning from life|General sense of well-being and mental health|Social connection and belonging|Ability to perform activities necessary for daily living|Satisfaction and stability in family life and connection|Occupational or academic functioning (including work as home manager)|Financial stability|Satisfaction from or ability to engage in romantic relationships, if desired"][textarea default=".    "    rows="2"]      
[checkbox name="expand_progress" value="" memo="Overall progress"][conditional field="expand_progress" condition="(expand_progress).is('')"]Overall progress is [select value="good|fair|poor"] considering that [select value="Client's overall functioning has improved|Client is maintaining level of functioning|Client is not currently responding to interventions|Client is precontemplative and needs motivational enhancement|Client is contemplative and needs further motivational enhancement|Client is decompensating|Client has not followed through with psychiatry referral"].[/conditional] [checkbox name="expand_goal1" value="" memo="Goal 1 progress"][conditional field="expand_goal1" condition="(expand_goal1).is('')"]Client shows [select name="gp1" value="progress|maintenance of progress|no progress"] toward goal to  [textarea value="" rows="2"] as evidenced by [select name="goalevid" value="|reduced sxs|increased functioning|increased sxs|lowered functioning"] [textarea value="" rows="1"][/conditional] [checkbox name="expand_goal2" value="" memo="Goal 2 progress"][conditional field="expand_goal2" condition="(expand_goal2).is('')"]Client shows [select name="gp2" value="progress|maintenance of progress|no progress"] toward goal to [textarea value="" rows="1"] as evidenced by [select name="goalevid" value="|reduced sxs|increased functioning|increased sxs|lowered functioning"] [textarea value="" rows="2"][/conditional] [checkbox name="expand_bar" value="" memo="Barriers"][conditional field="expand_bar" condition="(expand_bar).is('')"]Barriers to success include [checkbox value="current apprehension to engage in clinical interventions|current apprehension to engage in structured substance use treatment|current emotional distress due to unresolved trauma|limited social supports|dysfunctional interpersonal relationships|poor insight"][textarea default=". " rows="2"].[/conditional] [checkbox name="expand_str" value="" memo="Strengths"][conditional field="expand_str" condition="(expand_str).is('')"]Strengths for success include [checkbox value="expression of willingness to engage in treatment recommendations|positive social/natural supports|community connection|history of actively engaging in mental health treatment|intelligence|resourcefulness|resilience"] [textarea default=". " rows="2"].[/conditional]
[var name="first_name"] would benefit from [checkbox value="continuing psychotherapy|engaging in recovery meetings|continuing recovery meetings|engaging in recovery coaching|continuing recovery coaching|engaging in IOP|engaging in a support group|continuing support group|engaging in family therapy|continuing family therapy|enhanced psychosocial supports|increasing self-care|engaging in psychiatric intervention|continuing psychiatric intervention|engaging in higher level of care"][textarea default=".    "    rows="2"]      
PLAN
[checkbox name="plan" value="Continue individual psychotherapy to support Client in achieving goals|Discharge"] with [checkbox name="followup" value="follow up scheduled in 1 week|follow up scheduled in 2 weeks|follow up scheduled in 3 weeks|follow up scheduled in 4 weeks|Client to call to schedule follow up appointment|caregiver to call to schedule follow up appointment|appropriate referrals"][textarea default=".    "    rows="2"]      
SUBJECTIVE
arrived for session. This session is Obtained consent to treat using this modality. This session was medically necessary to address symptoms, improve functioning . Extended Session Length
first_name
first_name reports experiencing
. Meds Substance UseAdditional client quotes, stressors, relationship, financial, medical, legal, etc.

OBJECTIVE
Affect: .
Mood: .
Thought process: .
Thought content: .

Interventions & Response
SI/HI Risk Basic MI CBT Beh Activation Anxiety New Medical dx Narrative Exposure Misc

ASSESSMENT
first_name is currently displaying

first_name has problems with affect/physiological regulation that are impacting their functioning in some life domains, but are able to control affect at times.
From the client’s report and therapist observation, first_name has functional impairment in the following areas:

Overall progress Goal 1 progress Goal 2 progress Barriers Strengths
first_name would benefit from

PLAN
with

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.87, 159 form elements, 80 boilerplate words, 2 text boxes, 15 text areas, 104 checkboxes, 10 drop downs, 6 variables, 5 comments, 17 conditionals, 350 total clicks
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