Progress Note TS [Short]

[text name="first_name"] 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|urgent crisis|intake|xxxxxx"] session. This session is [select name="placeofservice" value="via telehealth with the client at their home in NY.| via telehealth with the client confirmed to be in NY."] [select name="gender_ID" value="They|She|He|Client|XXXXXX|Person|Patient|They"] [textarea name="presentation_text" default="presented as calm and cooperative, with casual dress, normal grooming and hygiene. No unusual movements or psychomotor changes." rows="4"]
[comment memo="note if: uncooperative; bizarre dress/inappropriate for weather, unkempt/poor grooming/hygiene, remarkable/unusual movements/psychomotor changes"] [var name="first_name"] reports [textarea name="concernstext" default="" rows="2"][checkbox name="concerns_check" value="depression or persistent sadness|anxiety or panic|trouble with organization, focus, or managing impulses|symptoms consistent with PTSD|obsessive thoughts and/or compulsions|mood swings|trouble getting to sleep or staying asleep|psychosis|neurocognitive concerns|recent life changes or significant loss|recent trauma|difficulty managing emotional reactions|interpersonal or family conflict"]. [var name="first_name"]'s session is medically necessary to address symptoms, and 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(' ')"] * Medical necessity/factors influencing length and/or frequency of sessions include: [checkbox name="extended_reasons" value="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|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 diagnositc 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]
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MENTAL STATUS EXAM --
AFFECT: [textarea name="Affect" default="Normal range, reactive and mood congruent." rows="1"]
[comment memo="Note if distressed, labile, detached, blunted, flat, shallow, tired, inappropriate/incongruent"]
MOOD: [textarea name="Mood_default" default="Euthymic, reactive and congruent with content." rows="1"]
[comment memo="Note if mildly/moderately/quite anxious, depressed, dysphoric, elevated, angry, irritable, hostile, etc or incongruent with content."]
THOUGHT PROCESSES & CONTENT: [textarea name="Thought_Process" default="Goal-directed and logical." rows="1"]
[comment memo="Note if disorganized."]
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MEDICAL/LEGAL CHANGES OR CONCERNS: [textarea name="Med_Changes" default=" None reported." Rows="2"]
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RISK ASSESSMENT: [textarea name="Risk" default="No evidence or report of suicidal or homicidal ideation." rows="1"]
[checkbox name="expand_safety" value="" memo="Safety concerns reported (expand)"][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|has a plan|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|LPC to complete mandated report to appropriate agency"].[/conditional]
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[var name="first_name"] displayed the following strengths and capabilities during the session: 
[checkbox name="strengths" value="motivation to progress in treatment|utilization of positive coping techniques|ability to express emotions|ability to receive feedback from therapist|awareness of emotions|awareness and honesty around negative coping techniques|ability to tolerate painful feelings|openness to trying new, positive behaviors|having compassion for self"]
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SESSION THEMES: The main themes of [var name="first_name"]'s session included: [checkbox name="newertopics" value="----MOOD MANAGEMENT----|Current symptoms/functioning|Symptom management|Management of depressive symptoms|Management of anxiety symptoms|Emotion dysregulation|Distress intolerance|Anger issues|Negative cognitions|----ADHD----|ADHD symptoms|ADHD treatment/medications|Self-esteem|Management of executive dysfunction
----GENDER/SEXUALITY----|Gender identity|Sexual orientation|Coming out process|Reactions from family/friends/others|----OTHER TOPICS----|Homework/assignment follow up|Goals/treatment plan review|Client history/background|----ATTACHMENT ISSUES---|Adult attachment style issues|Attachment anxiety and avoidance|Adult attachment anxiety|Fear of developing intimate relationships|Fear of interpersonal rejection and/or abandonment|Adult attachment avoidance|Fear of intimacy|Excessive need for self-reliance|Distrust of others
----RELATIONSHIP DISTRESS----|Relationship dissatisfaction|Conflict/argument with partner|Intimacy concerns|Infidelity/affair concerns|Child custody conflict|Codependency issues|Divorce issues|Trust concerns|Communication problems with partner|Breakup/acute relationship concerns|Abuse/IPV|Relationship trauma|----ADJUSTMENT DISORDER----|Adjustment to stressor(s)|Adjustment to workplace changes|Adjustment to job loss/change|Adjustment to relationship changes|Adjustment to family life changes|Adjustment to a developmental event|----GRIEF/LOSS----|Death of a family member|Death of a friend|Grief reactions|Processing past regrets|Processing grief|Processing a death/loss|----INTERPERSONAL PROBLEMS----|Interpersonal conflict(s)|Conflict with friends|Conflict with family of origin|Conflict with extended family|Conflict within nuclear family|Conflict with partner/spouse|Conflict with coworker(s)|Communication issues|Poor boundary setting|Difficulty saying no to others|Passive behaviors|Aggressive behaviors|----BEHAVIORAL HEALTH ISSUES----|Self-Care activities|Sleep difficulty/concerns|Nutrition/eating habits|Physical activity/exercise|------SUBSTANCE USE ISSUES----|Substance use concerns|Alcohol use concerns|Cannabis use concerns|Tobacco use concerns|Relapse prevention|----TRAUMA----|Family of origin dynamics|Past trauma event|Recent trauma event|Sexual trauma event|Childhood trauma|Past childhood abuse/neglect|----STRESSORS----|Life stressors|Stressor/coping mechanism(s)|Family dysfunction|Work problems|School problems|Bullying|Work-related stress|Negative work environment|Difficulty with work/life balance|Financial issues|Legal issues|Housing issues|Relationship issues|Parenting stress|----MEDICAL & HEALTH ISSUES----|Medical/health concerns|Medication concerns|New diagnosis|Physical pain|----RELIGIOUS ISSUES----|Religious/spiritual concerns|Other"][textarea name="otherother" default="" rows="2"]
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SESSION GOALS: Improve functioning, symptom reduction (and/or) [checkbox name="Goals" value="skill acquisition|improve health|maintain positive gains|reduce ineffective behaviors|safety planning|treatment review|termination/discharge"].
[textarea name="session_goals" default="" rows="1"]
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CLINICAL INTERVENTIONS: [checkbox name="Interventions" value="Therapist provided supportive validation and used reflective listening, along with aiding patient in processing thoughts, emotions and perceptions related to issues at hand and worked to develop more effective solutions/coping.|Therapist and patient worked on cognitive restructuring by challenging automatic negative thoughts that contribute to depression and anxiety, and identified cognitive distortions also influencing mood.|Therapist and patient reviewed the relationship between thoughts, feelings, and behaviors, and considered how to address ones feelings by modifying the other two constructs.|Therapist and patient worked on emotional experiencing and processing of feelings that arise around certain stressors or events, that historically are pushed down, buried, or otherwise repressed.|Therapist and patient considered the pitfalls of emotional avoidance including the onset or worsening of depression and anxiety. |Therapist and patient explored the patients stressors and frustrations.|Therapist utilized validation and empathy related to their frustrations and experiences.|Therapist and patient explored some ways to improve distress/frustration tolerance, including healthy distraction (with enjoyable activities, focusing on others, counting, and tasks/chores), radical acceptance, self-soothing techniques, mindfulness, coping thoughts, and self-affirming thoughts.|Therapist and patient explored fear of abandonment which is chronic and longstanding.|Therapist and patient discussed how fear of abandonment does not make healthy decisions whereas the logical and more thoughtful does, and we want to recognize who is making decisions for them at different times as a way of developing cognitive dissonance from the thoughts, impulses, and decisions that fear of abandonment self makes.|Therapist and patient explored tendencies towards perfectionism, and how this inherently implies a binary way of thinking, in which one has either been perfect or failed. We considered the inauthenticity of this thinking and how there is a spectrum between these points.|Therapist and patient considered how people make opinions of us based upon a number of interactions or data points such that an average is taken and the opinion is based upon this. Accordingly, one can have several positive data points which allows room to make some mistakes or have negative data points without drastically distorting the perception of us.|Therapist and patient worked on problematic reactions used to deal with extremely intense emotions and increasing understanding of what leads to problematic behaviors or responses to these emotions|Therapist and patient worked on relationship issues such as interpersonal conflict, role transitions, or grief that may contribute to the development or continuation of mental health problems or symptoms.|Therapist and patient worked on unconscious influences and feelings that may be related to past events and interactions which allows for better self awareness, change, and recovery.|Therapist used solution focused techniques to help client identify solutions that are effective to improve functioning and overall wellbeing.|Therapist assisted the client identifying cognitive distortions and used cognitive restructuring techniques to re-frame challenges and difficult feelings to positive outlooks for self.|Therapist and patient practiced assertive communication skills to increase interpersonal effectiveness.|Therapist guided the client through the examination of unresolved conflicts and significant past events to gain insight.|Therapist engaged client in collaborative problem-solving and conflict-resolution skill building activities.|Therapist and patient worked on building connecting past experiences to present behaviors.|Therapist aided the client in regulating and expressing emotions by providing a safe space for ventilation of thoughts and feelings without judgment.|Therapist assisted the client in gaining new insights into problems and symptoms.|Therapist and patient reviewed the client's treatment plan and discussed progress towards goals.|Therapist and patient worked on understanding and identifying emotional triggers and reviewed coping strategies client can utilize for emotional regulation.|Therapist provided psycho-education related to client's symptom presentation and introduced the concept of mindfulness to aid in self regulation.| Therapist taught patient a grounding technique and helped patient actively practice these within session. The patient responded well towards learning these strategies and was open to incorporating these outside of session.|Therapist and patient worked on completing a safety plan to address ongoing suicidal ideation and provide strategies and supports to utilize in managing distress and promoting safety."]
[comment memo="Anxiety TX"] [checkbox name="Anxiety" value="Therapist prompted patient to identify origins of anxiety related fears.|Therapist provided client with information related to cognitive distortions.|Therapist and patient discussed thoughts, feelings, and behaviors contributing to anxiety.|Therapist assisted client in identifying and reframing cognitive distortions.|Therapist transitioned session to focus on development of mindfulness skills to address anxiety symptoms.|Therapist taught client deep breathing techniques to better regulate and manage emotions.|Therapist and client practiced learned skills together in session.|Therapist validated client expression of emotions and praised client participation in session.|Therapist closed session by developing a plan for completion of therapy homework with client."]
[textarea name="intervention_text" default="" rows="1"] [checkbox name="more_interventions" value="" memo="expand more interventions"]
[conditional field="more_interventions" condition="(more_interventions).is('')"] [checkbox name="More_Interventions" value="Interventions and strategies included: |Primary interventions and strategies included: |Additional intervention and strategies included:|attuned listening|cognitive/behavioral techniques|emphasis on self-expression|normalization|psycho-education regarding symptom-management and skill building|play therapy|interpretation|parent education|DBT-informed|IFS protocol|validation|rapport building|emotional expression|relaxation techniques|supportive therapy|increase coping|identify/reframe thinking|problem-solving|positive reinforcement|communication skills|identify triggers|clarification|behavioral rehearsal|assertiveness training|art therapy|child behavioral strategies|reframing|active listening|setting appropriate boundaries|Tx plan review|strengthen support systems|family Hx/dynamics|trauma-informed interventions|role play|modeling|child-centered play therapy techniques|TF-CBT|cognitive restructuring|family therapy|expressive arts|focus on improved problem solving and coping|expressive art techniques|supportive techniques|emphasis on here-and-now functioning|evaluation and exploration of problematic automatic thoughts|targeting more effective problem solving and coping skills in daily life|addressing problematic core beliefs|evaluating and addressing dysfunctional thoughts|emphasis on self-monitoring of thoughts, emotions and behavior|techniques for the development of greater confidence and self-efficacy|self-assertiveness and confidence building|a focus on anger management and containment of acting out|exploration of appropriate interaction and communication|focus on social skills enhancement and practice|guided imagery used to improve mindfulness and improve impulse-control|review informed consent/confidentiality|clinical diagnostic assessment/clarification focused on empathetic validation, reassurance, and further exploring and naming emotions/experiences with the purpose of enhancing ego function, supporting mature defenses, and fostering insight into psychosocial stressors.|***OLD***|I used Motivational Interviewing strategies including open/closed ended questions and reflective listening.|I provided psychoeducation.|We collaborated on ....|I utilized person-centered counseling skills in order to build the therapeutic relationship.|I utilized active listening skills in order to gather information, promote insight and autonomy, convey empathy and understanding, and validate the client's experience.|We reviewed creation of treatment plan; client identified areas of concern and goals they would like to work on through therapy|I maintained focus on providing a supportive and responsive relationship with client to foster their ability to cooperate|I utilized circular questioning, reflecting feelings and metacommunication to support client in expressing and exploring their feelings.|I used metacommunication, circular questioning and gentle challenging to help client examine patterns in interpersonal relationships and to promote introspection regarding their emotions, thoughts and behaviors.|I utilized reflection and validation of feelings, encouragement and metacommunication throughout the session to help client gain insight.|We collaboratively participated in therapy activities intending to facilitate problem solving and interpersonal social skill development including expression of emotions and responses to emotions, as well as the examination of relational patterns.|I assisted client in progressing toward goals throughout the session by assessing current coping skills and encouraging expression of feelings and adaptation of coping skills, as well as exploring the development of additional ones. I also provided activities to strengthen the sensory response systems and self-regulation of the client through employing various therapy modalities and therapy techniques as appropriate.||Exploration and healthy expression of grief related to the loss of a loved one or relationship.|We utilized Internal Family Systems treatment methods ('parts work')|Identification and exploration of parts and their roles.|Exploration of parts that self has a tendency to blend with and identification of ways to unblend and separate from these parts.|Introduced and discussed basics of Dialectical Behavior Therapy (DBT)|Provided psychoeducation related to Dialectical Behavior Therapy skills training."]. [textarea name="moreinterventiontext" default="" rows="1"][/conditional] 
[checkbox name="mitigateornah" value="Addressing these psychological components should increase the response rate or at least mitigate symptoms, decreasing the risk for decompensation of underlying illness or the need for additional interventions or medications."]
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PROGRESS/RESPONSE: [textarea name="RTI" default=" Some progress is apparent. The patient was actively engaged throughout the session and responded well to the intervention offered. Treatment continues to show good evolution and development." rows="4"]
[checkbox name="more_RTI" value="" memo="expand more progress and RTI options"] [conditional field="more_RTI" condition="(more_RTI).is('')"][checkbox name="Progress" value="Fluctuating/intermittent progress apparent. Although the current crisis has overwhelmed the client's resources, they were engaged and communicative throughout the session.|Client is disengaged from the therapuetic process and progress is minimal.|Client is maintaining past gains and is stable. Current focus on maintenence and relapse prevention. We are moving toward termination via reduced session frequency.|some progress apparent|a significant reduction in symptoms continues|client actively participated in the counseling process|client participated actively in development of client-centered treatment plan|client was active and communicative throughout the session|client responded well to the intervention offered|treatment continues to show good evolution and development|client is engaged in the therapeutic process|client is disengaged from the therapuetic process|significant improvement|maintaining past gains/stable|near completion of treatment|current focus on maintenance/relapse prevention|some increase in symptoms|significant increase in symptoms|progress with self-understanding and self-insight|there is continued development of the clients capacity for self-care and life management|developments continue in the areas of family and relational functioning|developments continue in the areas of occupational functioning and achievement|developments continue in the areas of healthy separation and interdependence|developments continue in the area of containment of harmful acting out behavior|the client continues to make steady gains in self-esteem and confidence|current crisis has overwhelmed client’s resources|regressed|no notable change|slight progress|fluctuating/intermittent progress"].[textarea name="moreprogress_text" default="" rows="1"][/conditional]
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PLAN: [select name="plan" value="Treatment to continue as indicated, client to practice strategies discussed in session.|Increase session frequency due to increased symptoms or safety concerns|Decrease session frequency|Moving toward discharge, decrease session frequency and monitor for stability and maintenence of gains|Discharge and close file| xxxxxx|Higher level of care needed, referred to xxxxxx for assessment and indicated treatment before returning to outpatient treatment|"]
[checkbox name="more_plan" value="" memo="expand ongoing plan options"]
[textarea name="plan_text" default="" rows="2"]
[conditional field="more_plan" condition="(more_plan).is('')"][checkbox name="Plan" value="treatment to continue as indicated|increase/decrease session frequency|move toward discharge|discharge|referral to xxxxxx|higher level of care needed|follow up|homework|practice|follow up appointment scheduled|client/guardian will call to schedule follow up appointment|plan for next session: |"][textarea name="followup_text" default="" rows="2"][/conditional][select name="next" value="Next session |Treatment on hold. |File closed. |"][select name="scheduling" value=" |is scheduled for 1 week out. |is scheduled for 2 weeks out. |is scheduled for 3 weeks out. |is scheduled for 1 month out. |is scheduled for: |to be scheduled by client. |to be scheduled by guardian. |to be scheduled after assessment for higher level of care and completion of recommended treatment. "][textarea name="ending_text" default="" rows="2"]