IT Encounter

[text name="variable_1" default="Date"] - [text name="variable_2" default="Client Code"]; ([select name="variable_1" value="60 min|90    min|30 min"])

SUBJECTIVE: 
[text name="first_name" default="Client"] (pronouns: [checkbox name="pronouns" value="she/her|he/him|they/them"]) arrived [select name="on_time" value="on time|5-10 minutes late| more than 10 minutes late"] for [select name="scheduled_crisis" value="scheduled follow up|crisis|xxxxxx"] session. This session is[select name="placeofservice" value=" in person.| via telehealth with the client at their home in Texas.| via telehealth with the client confirmed to be in Texas."] Client [textarea name="presentation_text" default=" presents as calm and cooperative, with casual dress, normal grooming and hygiene." rows="2"] Client 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 HIV medications. |Client reports non-adherence with HIV medications.| Client reports compliance with psychotropic medications. |Client reports non-adherence with psychotropic medications. |Client reports adherence with all 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 methamphetamine 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="1"]

OBJECTIVE: 
Client affect [checkbox name="affect" value="normal range|distressed|tearful|labile|detached|flat|agitated|shallow|tired"].  Client 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"][checkbox name="tproc2" value=" disorganized"][checkbox name="tproc5" value=" tangential"][checkbox name="tproc3" value=" future-oriented"][checkbox name="tproc4" value=" past-oriented"].    Thought content[checkbox name="tcont1" value=" within normal limits"][checkbox name="tcont2" value=" features paranoid ideation"][checkbox name="tcont3" value=" features auditory hallucinations"][checkbox name="tcont4" value=" features visual hallucintations"][checkbox name="tcont5" value=" features delusions"][checkbox name="tcont6" value=" features low self-image"][checkbox name="tcont7" value=" features ideas of reference"][checkbox name="tcont" value=" features obsessions"].    [checkbox value="No evidence or report of SI/HI. "]        [comment memo="Interventions & Response"]   Therapist provided    empathetic listening    and support. [checkbox name="expand_safety" value="" memo="SI/HI Risk"][conditional field="expand_safety" condition="(expand_safety).is('')"]Client disclosed current safety concerns,    [checkbox name="Safety" value="denied suicidal ideation|reported passive suicidal ideation|reported active suicidal ideation|reported passive homicidal ideation|reported active homicidal ideation|denies plan/method/intent|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|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_mi" value="" memo="MI"][conditional field="expand_mi" condition="(expand_mi).is('')"]  Therapist 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="; client’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="Therapist described the interrelationship between thoughts, feelings, and behavior, and how negative patterns form and impact mood and functioning over time. "][checkbox name="cbt2" value="Therapist guided client in describing a recent event that activated distress. "][checkbox name="cbt3" value="Therapist provided client with information related to cognitive distortions. "][checkbox name="cbt4" value="Therapist guided client in identifying cognitive distortions that contribute to negative symptoms. "][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 therapist 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="Therapist encouraged client to keep a mood log and any accompanying cognitive distortions associated with moods/emotions. "][checkbox name="cbt8" value="Therapist 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="Therapist guided client in describing history, severity, and duration of depression symptoms and attempts by client to resolve it. "][checkbox value="Therapist reinforced acquired and natural adaptive coping methods, while highlighting those that seemed to have little or no effect. "][checkbox value="Therapist provided psychoeducation on behavioral activation, including the relationship between depression and motivation, and how even light activity can cultivate motivation. "][checkbox value="Therapist guided client in identifying an activity that client could commit to doing between sessions, and suggested that client observe what occurs with their sense of interest/motivation. "][checkbox value="Therapist 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="Therapist guided client in describing history, severity and duration of anxiety symptoms and attempts by client to resolve it. "][checkbox value="Therapist reinforced acquired and natural adaptive coping methods, while highlighting those that seemed to have little or no effect. "][checkbox name="anx0" value="Therapist prompted client to explore and identify anxiety-related fears. "][checkbox name="anx1" value="Therapist prompted client to identify where in the body tension is felt and to describe the sensation. "][checkbox value="Therapist and client discussed the role of substances in client's coping style, and their perceived effectiveness. "][checkbox name="anx2" value="Therapist demonstrated and guided client in practice of a deep-controlled breathing technique. "][checkbox name="anx3" value="Therapist demonstrated and guided client in practice of a grounding technique describing present experiences that relate to their 5 senses. "][checkbox name="anx4" value="Therapist guided client through progressive muscle relaxation technique. "][checkbox name="anx5" value="Therapist guided client through mindfulness/meditation practice. "][checkbox name="anx6" value="Client rated anxiety level at a ___ before    intervention and a ___ after the intervention (scale    0-10, 10 severe). "][checkbox name="anx7" value="Client seemed receptive to therapist’s suggestion of practicing the intervention between sessions. "][/conditional][checkbox name="expand_hivdx" value="" memo="New HIV dx"][conditional field="expand_hivdx" condition="(expand_hivdx).is('')"][checkbox value="Therapist engaged client in discussion about recent HIV diagnosis. "][checkbox value="Therapist guided client in exploring their emotions related to recent HIV diagnosis. "][checkbox value="Client connected with and processed feelings of ___. "][checkbox value="Therapist and client discussed societal and cultural stigma surrounding HIV and how it affects them. "][checkbox value="Therapist provided psychoeducation on HIV including transmission, risk reduction, disease progression, viral load, nutrition, exercise, the impact of substances, the importance of pharmacotherapy in disease management. "][checkbox value="Client demonstrated understanding of the information by engaging in discussion and asking appropriate questions. "][checkbox value="Therapist engaged client in identifying barriers to seeking medical care. "][checkbox value="Therapist utilized motivational interviewing techniques to develop discrepancy between life goals and HIV medication nonadherence. "][checkbox value="Therapist utilized Socratic questioning to explore client’s resistance to engaging with primary medical provider. "][checkbox value="Therapist and client collaborated on a plan to engage in primary care including:  "][checkbox value="exploring aspects of wellness that contribute to better management of HIV, 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="Therapist provided an overview of trauma exposure treatment, including safety and stability phase, exposure phase, and CBT phase. "][checkbox value="Therapist 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="Therapist guided client in imagining a box or container where the trauma content can be safely contained for the duration of treatment. Therapist suggested client commit to not “unpacking” content between sessions. Therapist explained that this practice is meant to decrease intrusive thoughts and ruminations about the trauma. "][checkbox value="Therapist 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="Therapist guided client in creating a sketch of the environment to aid in giving the verbal narrative. " ][checkbox value="Therapist 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. Therapist suggested that client limit writing time to a period of no more than 45 minutes. "][checkbox value="Therapist 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="Therapist engaged client in exploring residual thoughts and beliefs that stem from the trauma experience.  "][checkbox value="With guidance from therapist, 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 identifying and moving 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: 
Client 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 rows="1"].     [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="1"] as evidenced by [select name="goalevid" value="|reduced symptoms|increased functioning|increased symptoms|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 symptoms|increased functioning|increased symptoms|lowered functioning"] [textarea value="" rows="1"][/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 rows="1"].[/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 rows="1"].[/conditional]  Client would benefit from [checkbox value="continuing psychotherapy|engaging in recovery meetings|continuing recovery meetings|engaging in recovery coaching|continuing recovery coaching|engaging in IOP|continuing IOP|continuing SOP|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="1"].

PLAN: 
[checkbox name="plan" value="Continue IT to support client in achieving goals|Discharge|with follow-up scheduled for"] [text name="followupdate" default="Date"] at [text name="followuptime" default="Time"] [select name="followupampm" value="pm|am"].