JD Psychotherapy Outpatient MH Follow Up Note with expandable sections

[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="gender_ID" value="this|her|his|their"] [select name="scheduled_crisis" value="scheduled follow up|urgent crisis|intake|xxxxxx"] session, which was conducted [select name="teleplatform" value="via HIPAA compliant Telehealth by SimplePractice|via HIPAA compliant Zoom audiovisual meeting"] [select name="placeofservice" value="with the client at their home in WI.| with the client location confirmed to be in the state of WI.|in person at the clinic."]  This session was medically necessary to address symptoms, 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(' ')"] * Factors influencing length and/or frequency of sessions include: 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 [checkbox name="extended_reasons" value="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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PRESENTATION
[var name="first_name"] [textarea name="presentation_text" default=" presented with good hygiene, dressed in appropriate attire and in no acute distress. Client was generally cooperative and had good eye contact. No agitation or abnormal movements noted. Speech had good spontaneity and was normal in rate, tone and volume. Mood inferred as euthymic. Affect congruent with mood. Patient was logical and linear in thought process and appropriately able to engage and answer questions during session. Alert and oriented (x4). Judgment and insight were good."]
[checkbox name="specificmse" value=""][comment memo="Open Detailed MSE"]
[conditional field="specificmse" condition="(specificmse).is('')"]presented with [select name="hygeine" value="good|poor"] hygiene, dressed in [select name="2" value="appropriate|inappropriate|"] attire and in [select name="3" value="no acute|acute"] distress. Patient was [select name="4" value="polite|hostile|suspicious"] and [select name="5" value="generally cooperative|defensive|easily distracted"] and had [select name="6" value="good|poor"] eye contact. [select name="7" value="No response to internal stimuli|Response to internal stimuli"] was noted. [select name="8" value="No psychomotor retardation|Psychomotor retardation"] was noted. [select name="9" value="No agitation|agitation"] was noted. [select name="10" value="No abnormal|Abnormal"] movements are noted. Speech was [select name="11" value="normal in rate, tone and volume|pressured"]. Speech [select name="12" value="had good spontaneity|was impoverished"]. Mood was [select name="13" value="euthymic|dysphoric|euphoric|hostile"]. Affect was [select name="14" value="congruent|incongruent"] with mood. Patient was [select name="15" value="logical and linear|tangential"] in their thought process and [select name="16" value="appropriately able|unable"] to engage and answer questions during interview. The patient [select name="17" value="denied|reported"] suicidal ideation. Patient [select name="18" value="denied|reported"] homicidal ideation. Patient [select name="19" value="denied|reported"] auditory and visual hallucinations. Thought content was [select name="20" value="devoid of|contained"] auditory, visual and/or tactile hallucinations. [select name="21" value="No acute psychosis or mania is observed|Acute psychosis and/or mania is observed"]. Patient [select name="22" value="denied|reported"] feelings of paranoia, suspicion or derealization. Patient was [select name="23" value="alert and oriented to person, place, date and time (A&Ox3)|disoriented"]. Attention, concentration and memory were [select name="24" value="grossly intact|deficient"]. Judgment was [select name="25" value="good|poor|impaired"] and insight was [select name="26" value="good|fair|poor"] as evidenced by patient's [select name="27" value="awareness|lack of awareness"] of their mental health and illness, presenting here on [select name="28" value="voluntary|involuntary"] basis, [select name="29" value="motivation|lack of motivation"] in achieving treatment objectives of reduction of symptoms and [select name="30" value="continuing|disregarding"] follow-up care recommendations. Patient [select name="32" value="exhibits|does not exhibit"] capacity to understand the consequences of their own behaviors and ability to make decisions to ensure the safety of self and others. Patient is also [select name="33" value="contracting|not contracting"] for safety.
 [/conditional]
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FUNCTIONAL STATUS
[var name="first_name"] has problems with affect/physiological regulation that are impacting their functioning in some life domains, but are able to control affect at times.
From the client’s report and therapist observation, [var name="first_name"] has functional impairment in the following areas:
[checkbox name="chk_som" value="Sense of meaning from life|General sense of well-being and mental health|Social connection and belonging|Ability to perform activities necessary for daily living|Satisfaction and stability in family life and connection|Occupational or academic functioning (including work as home manager)|Financial stability|Satisfaction from or ability to engage in romantic relationships, if desired"]
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STRENGTHS
[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: review of current symptoms and functioning, [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|new diagnosis|homework/assignment follow up|goals/treatment plan review|client history/background|discharge planning|discussion related to medication"][checkbox name="addtlthemes" value=""][comment memo="More specific themes"][conditional field="addtlthemes" condition="(addtlthemes).is('')"], [checkbox name="newertopics" value="symptom management|management of depressive symptoms|management of anxiety symptoms|emotion dysregulation|distress intolerance|anger issues|negative cognitions|self-esteem|management of executive dysfunction|life stressors|stressor/coping mechanism(s)|family dysfunction|work or school problems|interpersonal conflict(s)|communication issues|school or work-related stress|difficulty with school or work/life balance|financial issues|legal issues|housing issues|relationship issues|parenting stress|substance use concerns|medical/health concerns|medication concerns|physical pain/injury|religious/spiritual concerns|gender identity|sexual orientation|coming out process|self-Care activities|sleep difficulty/concerns|nutrition/eating habits|physical activity/exercise|adjustment to stressor(s)|adjustment to identified change at work, home, or school|adjustment to relationship or family life changes|adjustment to a developmental event|death of a family member or friend|grief reactions|processing past regrets|processing a grief, death, or loss"][comment memo="More Specific Attachment/Relational/Trauma"] [checkbox name="themesofrelats" value="conflict with friends|conflict with family|conflict with coworker(s)|bullying|negative work or school environment|poor boundary setting|difficulty saying no to others|passive behaviors|aggressive behaviors|family of origin dynamics|past trauma event|recent trauma event|sexual trauma event|childhood trauma|past childhood abuse/neglect|adult attachment style issues|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 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"][/conditional]. [var name="first_name"] reports [textarea name="concernstext" default="generally feeling xxxx since the last session."]
[comment memo="**include changes in symptoms or functioning, medications, other treatment, legal, significant events, quotes, etc**"]
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CLINICAL INTERVENTIONS: [checkbox name="Interventions" value="We 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.|We 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.|We worked on unconscious influences and feelings that may be related to past events and interactions which allows for better self awareness, change, and recovery.|I used solution focused techniques to help client identify solutions that are effective to improve functioning and overall wellbeing.|I assisted the client identifying cognitive distortions and used cognitive restructuring techniques to re-frame challenges and difficult feelings to positive outlooks for self.|We practiced assertive communication skills to increase interpersonal effectiveness.|I guided the client through the examination of unresolved conflicts and significant past events to gain insight.|I engaged client in collaborative problem-solving and conflict-resolution skill building activities.|We worked on building connecting past experiences to present behaviors.|I aided the client in regulating and expressing emotions by providing a safe space for ventilation of thoughts and feelings without judgment.|I assisted the client in gaining new insights into problems and symptoms.|We reviewed the client's treatment plan and discussed progress towards goals.|We worked on understanding and identifying emotional triggers and reviewed coping strategies client can utilize for emotional regulation.|I provided psychoeducation related to client's symptom presentation and introduced the concept of mindfulness to aid in self regulation.|I provided supportive validation and used reflective listening, along with aiding client in processing thoughts, emotions and perceptions related to issues at hand and worked to develop more effective solutions/coping.|We worked on cognitive restructuring by challenging automatic negative thoughts that contribute to depression and anxiety, and identified cognitive distortions also influencing mood.|We reviewed the relationship between thoughts, feelings, and behaviors, and considered how to address ones feelings by modifying the other two constructs.|The patient and I worked on emotional experiencing and processing of feelings that arise around certain stressors or events, that historically are pushed down, buried, or otherwise repressed. We considered the pitfalls of emotional avoidance including the onset or worsening of depression and anxiety.|We explored the patients stressors and frustrations.|I utilized validation and empathy related to their frustrations and experiences.|We 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.|We explored fear of abandonment which is chronic and longstanding.|I taught client deep breathing techniques to better regulate and manage emotions.|We practiced newly learned skills together in session.|I taught client a grounding technique and helped client actively practice these within session.|We worked on completing a safety plan to address ongoing suicidal ideation and provide strategies and supports to utilize in managing distress and promoting safety."]
[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="Therapist prompted client to identify origins of anxiety related fears.|Therapist provided client with information related to cognitive distortions.|Therapist and client 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.|We 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. We further 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.|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.|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 apparent. The client 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:
[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|No evidence or report of safety concerns in need of action by therapist"].[/conditional]
[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"]