Intake Assessment Valant

Treatment Approach
[checkbox name="variable_1" value="Dialectical behavior therapy to learn new skills to address behaviors and emotions that have been identified as causing problems in life;Person centered therapy approaches including providing unconditional positive regard, empathetic understanding, and genuineness|Cognitive Behavioral Therapy for the exploration of patterns of certain thoughts, feelings and behaviors;Person centered therapy approaches including providing unconditional positive regard, empathetic understanding, and genuineness|Cognitive processing Theory to help client learn how to modify and challenge unhelpful beliefs related to the trauma; Cognitive Theory to assist client with modifying the pessimistic evaluations and memories of trauma, with the goal of interrupting the disturbing behavioral and/or thought patterns that have been interfering in daily life"]
*Chief Complaint*
Date and Time of Service:[date default="today"] [text size="8"]
 is see in this intake for [checkbox value="depression|anxiety|psychosis|substance abuse|cognitive impairment|impulsivity|mood lability|sleep disturbance|alcohol dependence|opiate dependence|autism spectrum disorder"] [textarea memo="other" default="" rows="1"]
[textarea memo="quotes" default="" rows="1"]
*Interval History*
 presents as [comment memo="SYMPTOM"][checkbox value="depressed|anxious|aggressive|impulsive|inattentive|irritable|withdrawn|unable to sleep|delusional|auditory hallucinations|visual hallucinations"] [textarea memo="other" default="" rows="1"]
Which is described as[comment memo="SEVERITY "][checkbox value=" the same as it has been| better| somewhat worse than it has been| significantly worse than it has been"] [textarea memo="other" default="" rows="1"]
 notices that it is sometimes improved by [comment memo="Modifying factors "][checkbox value="talking to someone|being alone|doing something physical like walking|doing something that is distracting"] [textarea memo="other" default="" rows="1"]
History of Presenting Illness:
[textarea rows="6"]
Current Psychiatric Medications:
[textarea rows="4"]
Current Suicidal Ideation:
[select value="denied|yes with no plan|yes with a plan|not suicide but thoughts of being better off dead"][checkbox value="contracts for safety|cannot contract for safety"] [textarea rows="1"]
Guns in the home / access to guns:
[select value="denied|yes "][textarea rows="1"][checkbox value=" Explained that we ask this question because guns in the home increase the risk of suicide, homicide and accidental death, Provided education about the importance of keeping guns locked and separated from ammunition. Explained that should this provider feel that  is unsafe to self or others, provider and  will work together to develop a safe place to keep weapons to decrease risk of impulsive suicide or homicide"]
Current Substance Use:
[select value="Denied|Reports positive for "][checkbox value="alcohol|tobacco|cannabis|opiate use|methamphetamine use"] [textarea rows="1"]
 identifies the following symptoms: [comment memo="Pertinent System "][checkbox value="irritability|mood instability|heightened anxiety|attention problems|troubled by hallucinations|fearfulness|nightmares|alcohol cravings|opiate cravings"] [textarea memo="other" default="" rows="1"]
Other systems:
Neurological - [checkbox value="Headaches|weakness|disturbed sleep|denied"] [textarea memo="other" default="" rows="1"]
GI - [checkbox value="Upset stomach|nausea|constipation|heatburn|denied"] [textarea memo="other" default="" rows="1"].
All other systems negative
*Past/Family/Social History* [comment memo="Include for 99214 + 99215"]
[textarea rows="3"]
Social Supports:
[checkbox value="none|significant other|extended family|children|friends|church members"]
Marital status:
[select value="married|partnered|single|"][textarea rows="1"]
Children:
[select value="0|1|2|3|4|5|6|7|"][textarea rows="1"]
Lives:
[select value="with significant other|alone|with children|with extended family|with parents|"][textarea rows="1"]
Works:
[select value="on disability|retired|unemployed|works as a |"][textarea rows="1"]
Financial Concerns:
[select value="none|related to healthcare costs|related to supporting family|"][textarea rows="1"]
Source of Income:
[select value="disability|social security|unemployment|work|family support|"][textarea rows="1"]
Housing Concerns:
[select value="none|unstable housing situation related to |"][textarea rows="1"]
Spirituality:
[select value="Christian|Catholic|Muslim|Jewish|Spiritual but not practicing|Athiest|Agnostic|"]
Sexual Orientation:
[select value="heterosexual|homosexual|bisexual|declined to answer|unable to assess due to symptomatic presentation|"]
Military:
[select value="denied|retired |active |"][textarea rows="1"]
Legal Concerns:
[select value="denied|"][textarea rows="1"]
HISTORIES:
[comment memo="All Information below is historical and not to be counted as part of the progress note"]
Previous Psychiatric Medications:
[textarea rows="1"]
Previous Psychiatric Hospitalization (s):
[select value="none|"][textarea rows="1"]
Previous Therapy:
Family History of Substance Use or Psychiatric Illness:
History of Suicide Attempt (s):
Family History of Suicide Attempt (s) or Completed Suicide:
History of Abuse:
[checkbox value="Time spent in psychotherapy: "][checkbox value="16-37 min"][comment memo="30 min 90833"][checkbox value="38-52 min"][comment memo="45 min 90836"][checkbox value="53-67 min"][comment memo="60 min 90838"]
[checkbox value="Focus of psychotherapy: "][checkbox value="interpersonal conflict|emotional experience related to diagnosis|identification of coping mechanisms|grief counseling"][textarea memo="other" default="" rows="1"]
Treatment Approach

*Chief Complaint*
Date and Time of Service:
is see in this intake for other
quotes
*Interval History*
presents as SYMPTOM other
Which is described asSEVERITY other
notices that it is sometimes improved by Modifying factors other
History of Presenting Illness:

Current Psychiatric Medications:

Current Suicidal Ideation:

Guns in the home / access to guns:

Current Substance Use:

identifies the following symptoms: Pertinent System other
Other systems:
Neurological - other
GI - other.
All other systems negative
*Past/Family/Social History* Include for 99214 + 99215

Social Supports:

Marital status:

Children:

Lives:

Works:

Financial Concerns:

Source of Income:

Housing Concerns:

Spirituality:

Sexual Orientation:

Military:

Legal Concerns:

HISTORIES:
All Information below is historical and not to be counted as part of the progress note
Previous Psychiatric Medications:

Previous Psychiatric Hospitalization (s):

Previous Therapy:
Family History of Substance Use or Psychiatric Illness:
History of Suicide Attempt (s):
Family History of Suicide Attempt (s) or Completed Suicide:
History of Abuse:
30 min 90833 45 min 90836 60 min 90838
other

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Sandbox Metrics: Structured Data Index 0.56, 70 form elements, 123 boilerplate words, 1 text boxes, 26 text areas, 1 dates, 18 checkboxes, 15 drop downs, 9 comments, 117 total clicks
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