Psychotherapy Follow Up Note – New Format

[text name="name" default="{NAME}"] is a self-identified [select name="gender" value="female|male|non-binary"] who presents today on HIPAA compliant [select name="platform" value="SimplePractice|Zoom|Google Meet|telehealth"] platform as client was attending from their home address. Participants in the session include this writer and [checkbox name="particpants" value="client|client's parent|client's spouse|client's family member(s)"] Client is aware of how the telehealth appointment will proceed; agreement to a communication back up plan if connection fails; client is aware of the risks and limitations of telehealth appointment; suitable electronic connection has been established; client is satisfied with the level of privacy of current environment; client’s identity has been established; client fits within therapist’s scope for telehealth.

SUBJECTIVE/CHIEF COMPLAINT:
[var name="name"] expressed the following about the problem, "[textarea name="problem" default="" rows="2"]".
The following concerns/updates since last session were addressed, [textarea name="concerns" default "" rows="2"]

[var name="name"] continues to report symptoms consistent with [text name="dx" default="{DIAGNOSIS}"], including:
[checkbox name="symptoms" value="Depressed mood|Sadness|Anhedonia|Tearful or crying spells|Fatigue/low energy|Negative cognitions|Restlessness|Difficulty sleeping|Trouble falling asleep|Appetite changes|Low motivation|Difficulty with organization|Hyperactivity|Inattention|Task avoidance|Difficulty with task initiation|Difficulty handling transitions|Difficulty persisting on challenging or tedious tasks|Concrete/literal thinking|Difficulty handling ambiguity/uncertainty|Sensory difficulties|Poor academic/work performance|Isolation from others|Loneliness|Low self-esteem|Anxiety of social situations|Concerns of negative evaluation by others|Fear of embarrassing self|Panic/Abrupt surge of intense fear/intense discomfort|Worry about having future panic symptoms/attacks|Difficulty concentrating|Muscle tension|Feeling on edge|Difficulty controlling worry/excessive worrying|Worry about work/school|Worry about health|Worry about finances|Panic attacks|Fear|Hopelessness|Feelings of worthlessness/inappropriate guilt|Intrusive thoughts|Flashbacks|Dissociation/Depersonalization/Derealization|Avoidance of thoughts/memories of traumatic event|Impulsivity|Obsessions/compulsions|Phobias|Self-harm|Substance abuse|Nightmares|Hypervigilance/Easily startled|Grief|Worry about future of relationship|Low self-confidence|Interpersonal conflicts|Irritability|Emotional instability|Other"][text name ="other" default"" size="75"]

Focus/themes of session for today was:
[checkbox name="topics" 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"][text name="other" default="" size="75"]

Changes in medication: [textarea name="medication" default="" rows="2"]

OBJECTIVE/MENTAL STATUS EXAM:
Orientation: [select name="MSE_1" value="Alert and oriented x4|unable to assess due to cognitive impairment"]
Time: [select name="time" value= "On time|Late"] 
Appearance: [select name="appearance" value="Clean/Neat|Casual|Desheveled"]
Affect: [checkbox name="MSE2" value="Full range|Flat|Blunted|Labile|Tearful at times|Flat, tearful & congruent with depressed & anxious mood|Appropriate to mood and thoughts|Inappropriate to mood and thoughts|Restricted in range, mood congruent"]
Mood: [checkbox name="mood" value="Euthymic|Depressed|Anxious|Irritable|Elevated|Other"][text name="other2" default=""] 
Speech: [checkbox name="MSE4" value="WNL|Normal rate and rhythm, not pressured|Pressured at times|Soft"] 
Behavior: [checkbox name="MSE_5" value="WNL|Appropriate|Inappropriate"]
Thought process: [checkbox name="MSE_6" value="WNL|Logical, linear, goal directed|Circumstantial|Circumstantial but redirectable|Tangential"]
Insight/Judgement [select name="insight" value="Good|Fair|Limited|Poor"]
A/V Hallucinations: [checkbox name="MSE8" value="No history|Denied A/V hallucinations|Endorsed auditory hallucinations|Denied auditory hallucinations| Denied visual hallucinations|Endorsed visual hallucinations"]

ASSESSMENT:
Safety/Risk Factors
[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]

Symptoms are consistent with:
[checkbox name="diagnosis" value="Anxiety disorders|Trauma and stressor related disorders|Depressive disorders|Adjustment disorders|Neurodevelopmental disorders/ADHD/ASD|Other"] [text name="other" default=""]

Assessments completed and scores: 
[checkbox name="00" value="None"][checkbox name="PHQ" value= "PHQ9"][conditional field="PHQ" condition="(PHQ).is('PHQ9')"][text name="score1" default=""][checkbox name="GAD" value= "GAD7"][/conditional][conditional field="GAD" condition="(assessments).is('GAD7')"][text name="score2" default=""][checkbox name="PCL" value= "PCL5"][/conditional][conditional field="PCL" condition="(assessments).is('PCL5')"][text name="score3" default=""][/conditional][checkbox name="DES_" value= "DES"][conditional field="DES_" condition="(DES_).is('DES')"][text name="score4" default=""][/conditional][checkbox name="SCARED_" value= "SCARED"][conditional field="SCARED_" condition="(SCARED_).is('SCARED')"][text name="score5" default=""][/conditional][checkbox name="ASRS" value= "ASRS1.1"][conditional field="ASRS" condition="(ASRS).is('ASRS1.1')"][text name="score6" default=""][/conditional]

From the client’s report and therapist observation, [var name="name"] is experiencing impairment in the following areas:
Sense of meaning: [select name="functioning1" value="No|Mild|Moderate|Severe"] disruption to the client’s sense of meaning from life.
General wellbeing: [select name="functioning1" value="No|Mild|Moderate|Severe"] disruption to the client’s general sense of wellbeing and mental health in a way that the client can provide for self and dependent others.
Social/friendships: [select name="functioning2" value="No|Mild|Moderate|Severe"] disruption to the client’s ability to engage and/or derive satisfaction from social connections. 
Daily tasks: [select name="functioning3" value="No|Mild|Moderate|Severe"] disruption to the client’s ability to perform daily necessary tasks for life. 
Family: [select name="functioning4" value="No|Mild|Moderate|Severe"]  disruption to the client’s satisfaction and stability in family life and connection.
Work/Academic: [select name="functioning5" value="No|Mild|Moderate|Severe"] disruption to the client’s satisfaction or productivity in the client’s function at work/school.
Economic: [select name="functioning6" value="No|Mild|Moderate|Severe"] disruption to the client’s financial stability. 
Romantic relationships: [select name="functioning7" value="No|Mild|Moderate|Severe"] disruption to the client’s satisfaction from or ability to engage in romantic relationships.

[var name="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"]
 
INTERVENTIONS:
In session interventions included:
[checkbox name="interventions2" value="----MOOD DISORDER INTERVENTIONS----|Active listening and feedback|Validated and normalized thoughts/emotions|Supportive reflection|Open-ended questions|Socratic questioning|Self-disclosure|Psychoeducation|Rapport building|Clarification|Reframing|Praise and encouragement|Reassurance|Assessment of client history|----ADHD----|Encouraging use of positive self-talk exercises|Exploration of time management skills|Exploration of organizational skills|Exploration of prioritization skills|Encouraging outside reading on ADHD/neurodivergence|Providing education about ADHD/neurodivergence|Identifying strengths/positive qualities|Exploration of social constructs|----COGNITIVE BEHAVIORAL THERAPY----|Introduction to the CBT model|Cognitive challenging|Cognitive restructuring|Identification/modification of dysfunctional assumptions/biases|Identification of distorted automatic thoughts|Reviewing negative thinking patterns|Identifying negative thinking patterns using examples from client's life|Reviewing 'feelings wheel'|Developing alternative thoughts and beliefs|Exploring how thoughts/beliefs influence mood and behaviors|----INTERPERSONAL INTERVENTIONS----|Exploration and education of communication skills to address interpersonal concerns|Education of assertive communication skills|Exploration of interpersonal patterns|Identifying and discussing boundary setting|Assisting client with practicing communication tools|----TREATMENT REVIEW----|Reviewing homework|Reviewing client's treatment plan and discussing progress towards goals|Goal setting|Administration of clinical assessments|Exploration of termination|Planning termination|Reviewing treatment frequency|----GENERAL INTERVENTIONS----|Reviewing family hx/dynamics|Role playing|Modeling|Problem-solving|Identifying/labeling emotions|Processing thoughts and feelings|Identifying negative coping and defense mechanisms|Providing psychoeducation on presenting concerns|Providing resources/literature to review|Identifying barriers to treatment/progress|----STRESS MANAGEMENT/COPING----|Provided psychoeducation on stress management interventions|Stress management intervention: deep breathing|Stress management intervention: PMR|Subjective Unit of Distress (i.e., SUDs)|Mindfulness practices|Grounding techniques|Identifying and planning enjoyable physical activities|Practicing progressive muscle relaxation|Guided imagery|Diaphragmatic breathing|----BEHAVIORAL HEALTH INTERVENTIONS----|Explored self-care strategies|Sleep hygiene interventions|Behavioral activation|Introduced SMART Goals|Identifying positive self affirmations|Identifying and reviewing positive coping skills|Identifying hobbies/values|Discussing benefits/effectiveness of medication|----MOTIVATIONAL INTERVIEWING----|Eliciting change talk|Eliciting alternative behaviors|Identifying pros/cons to change|Assessing readiness for change|----COUPLES & FAMILIES----|Parenting skills:exploring and reviewing effective parenting strategies|Exploration of family dynamics|Facilitating healthy expression of feelings/concerns|Identifying strengths/support system|Exploration of activities to enhance feelings of positive connection|Processing the aftermath of an argument or regrettable incident|Exploration of patterns of closeness and distance in the relationship|Exploration of couple's communication cycles|Observing and providing feedback on couple's communication and interactions|Exploration of family of origin/dynamics|Explored solvable and perpeptual problems|----DBT INTERVENTIONS----|DBT/Emotion regulation skills|DBT/Distress tolerance skills|DBT/Interpersonal effectiveness skills|Exploration of coping patterns|Exploration of emotions|Exploration of relationship patterns|Exploration of maladaptive cyclical patterns|Interpersonal interventions|Interactive feedback/process comments|Mindfulness|----TRAUMA & GRIEF/LOSS----|
Exploration of trauma and impacts on client's life|Exploration of potential reasons for behaviors/symptoms|Exploration of patterns of avoidance|Identifying consequences of avoidance|Providing psychoeducation on role avoidance plays in maintaining PTSD symptoms|Providing psychoeducation on PTSD symptoms|Identifying and processing issues around grief/loss|Exploration of trauma/abuse|Identifying triggers|Identifying alternative behaviors/coping skills that have helped in the past|Exploration and identifying strengths and support system"]


The client’s observable reaction to these interventions were: [checkbox name="reactions" value="positive|engaged|motivated| open|resistant|reluctant|negative|hesitant"]

Treatment progress:
Client progress in achieving treatment goals is best assessed as [checkbox name="progress1" value="responding well to interventions|making some progress|slow/slight progress|fluctuating/intermittent progress|maintaining past gains|maintaining current goal focus|an increase in symptoms|a decrease in symptoms|a significant escalation in symptoms|minimal|improving|stable"] as evidenced by client self-report, observed behavior, and level of engagement.

PLAN:
Changes in diagnosis or treatment plan: [textarea box="changes" value="None" rows="2"]

Frequency of sessions:
[checkbox name="plan1" value="Weekly individual therapy.|Biweekly individual therapy.|Return in 1-2 weeks.|Return in 2 weeks to assess functioning and review progress.|Return in 1 month to assess functioning and review progress.|Client will contact Provider to schedule next session.|Provider will contact Client to schedule next session."]

Plan for next session is to review [checkbox name="checkon" value="homework/outside assignment|recent stressors/emotional experiences|symptom intensity/frequency|goal achievement/outcomes"]
Therapist will also follow up on [checkbox name="followup" value="activity scheduling|reframing/identifying cognitive distortions|mindfulness exercises|self care|spending time with others|prioritization/time management|setting/maintaining boundaries|utilization of communication tools|utilization of coping strategies|journaling|modifying eating/exercise habits|other"][textarea name="other" default="" rows="2"]

Homework: [var name="name"] agreed to [textarea name="homework" default="" rows="2"].

The service provided is medically necessary and appropriate for the treatment of the diagnosed condition to: [checkbox name="neccessity" value="Address symptoms/achieve symptomatic relief.|Improve functioning in one or more life domains.|Maintain progress/prevent decompensation.|Prevent higher level-of-care/avoid hospitalization."]

[checkbox name="Extended" value=" "][comment memo="Extended Length Session"]
[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="variable_17" default=" "][/conditional]
is a self-identified who presents today on HIPAA compliant platform as client was attending from their home address. Participants in the session include this writer and Client is aware of how the telehealth appointment will proceed; agreement to a communication back up plan if connection fails; client is aware of the risks and limitations of telehealth appointment; suitable electronic connection has been established; client is satisfied with the level of privacy of current environment; client’s identity has been established; client fits within therapist’s scope for telehealth.

SUBJECTIVE/CHIEF COMPLAINT:
name expressed the following about the problem, "
".
The following concerns/updates since last session were addressed,


name continues to report symptoms consistent with , including:


Focus/themes of session for today was:


Changes in medication:


OBJECTIVE/MENTAL STATUS EXAM:
Orientation:
Time:
Appearance:
Affect:
Mood:
Speech:
Behavior:
Thought process:
Insight/Judgement
A/V Hallucinations:

ASSESSMENT:
Safety/Risk Factors

Safety concerns reported (expand)


Symptoms are consistent with:


Assessments completed and scores:


From the client’s report and therapist observation, name is experiencing impairment in the following areas:
Sense of meaning: disruption to the client’s sense of meaning from life.
General wellbeing: disruption to the client’s general sense of wellbeing and mental health in a way that the client can provide for self and dependent others.
Social/friendships: disruption to the client’s ability to engage and/or derive satisfaction from social connections.
Daily tasks: disruption to the client’s ability to perform daily necessary tasks for life.
Family: disruption to the client’s satisfaction and stability in family life and connection.
Work/Academic: disruption to the client’s satisfaction or productivity in the client’s function at work/school.
Economic: disruption to the client’s financial stability.
Romantic relationships: disruption to the client’s satisfaction from or ability to engage in romantic relationships.

name displayed the following strengths and capabilities during the session:


INTERVENTIONS:
In session interventions included:



The client’s observable reaction to these interventions were:

Treatment progress:
Client progress in achieving treatment goals is best assessed as as evidenced by client self-report, observed behavior, and level of engagement.

PLAN:
Changes in diagnosis or treatment plan:


Frequency of sessions:


Plan for next session is to review
Therapist will also follow up on


Homework: name agreed to
.

The service provided is medically necessary and appropriate for the treatment of the diagnosed condition to:

Extended Length Session

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.68, 77 form elements, 384 boilerplate words, 13 text boxes, 7 text areas, 29 checkboxes, 14 drop downs, 5 variables, 1 comments, 8 conditionals, 473 total clicks
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