Individual Therapy Note

SUBJECTIVE: [text name="first_name" default="Ct"] 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" value=" in person.| via telehealth with the client at their home in TX.| via telehealth with the client confirmed to be in TX."] 
Ct [textarea name="presentation_text" default=" presents as calm and cooperative, with casual dress, normal grooming and hygiene." rows="2"] 
Ct reports experiencing [checkbox name="concerns" value="depression|sadness|anxiety|anger|distress|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="Ct reports adherence with HIV medications. |Ct reports non-adherence with HIV medications. |Ct reports adherence with psychotropic medications. |Ct reports non-adherence with psychotropic medications. |Ct reports adherence with all medications. "][/conditional][checkbox name="expand_sub" value="" memo="Substance Use"][conditional field="expand_sub" condition="(expand_sub).is('')"][checkbox value="Ct reports continued abstinence. |Ct reports continued from primary substance. |Ct endorses recent alcohol use. |Ct endorses recent mehtamphetamine use. |Ct endorses recent cocaine use. |Ct endorses recent cannabis use. |Ct endorses recent use of sedative/hypnotics. |Ct endorses recent substance use. "][/conditional]
[comment memo="Additional client quotes, stressors, relationship, financial, medical, legal, etc."][textarea name="SubExt" default="" rows="1"]
OBJECTIVE: Ct affect [checkbox name="affect" value="normal range|distressed|tearful|labile|detached|flat|agitated|shallow|tired"].    
Ct 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="Ct oriented to person, place, time, situation. "]
[checkbox value="No evidence or report of SI/HI. "]
[comment memo="Interventions & Response"][textarea default="" rows="1"]
[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_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 Ct on a plan of action|avoiding argumentation|reflective listening"][checkbox name="mi8" value=", to influence Ct’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 Ct in describing a recent event that activated distress. "][checkbox name="cbt3" value="Thpst provided Ct with information related to cognitive distortions. "][checkbox name="cbt4" value="Thpst guided Ct in identifying cognitive distortions that contribute to negative sxs. "][checkbox name="cbt5" value="Ct was able to identify more realistic cognitions to replace the distortions and has committed to internalizing them. "][checkbox name="cbt6" value="Ct receptive to Thpst challenging Ct’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 Ct 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 Ct to describe an activating event, associated feelings, identify cognitive distortions, and challenges Ct to identify realistic alternative thoughts/beliefs to replace the distortions. "][checkbox name="cbt9" value="Ct seemed receptive to the above interventions. "][checkbox name="cbt10" value="Ct 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 Ct 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 Ct in identifying an activity that Ct could commit to doing between sessions, and suggested that Ct observe what occurs with their sense of interest/motivation. "][checkbox value="Thpst guided Ct in identifying activities that Ct 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 Ct 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 Ct 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 Ct discussed the role of substances in Ct's coping style, and their perceived effectiveness. "][checkbox name="anx2" value="Thpst demonstrated and guided Ct in practice of a deep-controlled breathing technique. "][checkbox name="anx3" value="Thpst demonstrated and guided Ct in practice of a grounding technique describing present experiences that relate to the 5 senses. "][checkbox name="anx4" value="Thpst guided Ct through progressive muscle relaxation technique. "][checkbox name="anx5" value="Thpst guided Ct through a guided meditation. "][checkbox name="anx6" value="Ct rated anxiety level at a ___ and a ___ (0-10, 10 severe) before and after the intervention, respectively. "][checkbox name="anx7" value="Ct seemed receptive to Thpst’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="Thpst engaged Ct in discussion about recent HIV dx. "][checkbox value="Thpst guided Ct in exploring their emotions rx’d to recent HIV dx. "][checkbox value="Ct connected with and processed feelings of ___. "][checkbox value="Thpst and Ct discussed societal and cultural stigma surrounding HIV and how it affects them. "][checkbox value="Thpst 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="Ct 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 Ct’s resistance to engaging with primary medical provider. "][checkbox value="Thpst and Ct collaborated on a plan to engage in primary care including  "][checkbox value="Thpst and Ct explored 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="Thpst provided an overview of trauma exposure treatment, including safety and stability phase, exposure phase, and CBT phase. "][checkbox value="Thpst guided Ct in learning how to scale anxiety/stress on a scale from 0-10 (10 severe), and engaged Ct in a deep controlled breathing exercise. Ct’s scores were __ and __ before and after the exercise, respectively.  "][checkbox value="Ct 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 Ct in imagining a box or container where the trauma content can be safely contained for the duration of treatment. Thpst suggested Ct 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 Ct 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 Ct limit writing time to a period of no more than 45 minutes. "][checkbox value="Thpst engaged Ct in providing a detailed verbal narrative of the trauma experience, pausing the narrative to process emotions as they surface. "][checkbox value="Ct repeated the scaling and breathing exercises at the end of session, reporting scores of ___ and ___, respectively.  "][checkbox value="Ct reported resolution of emotional activation that surfaced during the narrative exposure. "][checkbox value="Thpst engaged Ct in exploring residual thoughts and beliefs that stem from the trauma experience.  "][checkbox value="With guidance from Thpst, Ct was able to identify distortions and replace these cognitions with more realistic and factual statements.  "][checkbox value="Ct committed to practice rehearsing the new statement as the old thought/belief arises. "][checkbox value="Ct 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]
ASSESSMENT: Ct 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="Ct's overall functioning has improved|Ct is maintaining level of functioning|Ct is not currently responding to interventions|Ct is precontemplative and needs motivational enhancement|Ct is contemplative and needs further motivational enhancement|Ct is decompensating|Ct 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('')"]Ct 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 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('')"]Ct 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="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]
Ct 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 Ct 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 4 weeks|appropriate referrals"][textarea rows="1"].
SUBJECTIVE: arrived for session. This session is
Ct

Ct reports experiencing
.
Meds Substance Use
Additional client quotes, stressors, relationship, financial, medical, legal, etc.

OBJECTIVE: Ct affect .
Ct mood .
Thought process .
Thought content .


Interventions & Response

SI/HI Risk MI CBT Beh Activation Anxiety New HIV dx Narrative Exposure Misc
ASSESSMENT: Ct is currently displaying
.
Overall progress Goal 1 progress Goal 2 progress Barriers Strengths
Ct would benefit from
.
PLAN: with
.

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Sandbox Metrics: Structured Data Index 0.89, 142 form elements, 31 boilerplate words, 1 text boxes, 13 text areas, 101 checkboxes, 10 drop downs, 2 comments, 15 conditionals, 267 total clicks
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