Racheal Progress Note

Ct located in [checkbox name="cb6" value="home for telehealth appt|office"]


AGENDA:
[checkbox name="cb6" value="Review insights from previous session|Review homework|Review assessments, screeners, and scoring|Assess mood/functioning|Assess relationship distress|Assess sexual functioning/concerns|Psychoeducation|Psychosexual education|Communication skills training|Emotion regulation skills training|Behavioral health interventions|Stress management|Pain management|Mindfulness|Safety Planning|Review of Progress|Review diagnostic conclusions/recommendations|Treatment Planning|Goal setting|Termination planning|Discuss termination|Termination "]

ASSESSSMENTS, SCREENERS, & SCORING
[checkbox name="cb7" value="Self-report and Behavioral Observation|PHQ-9|GAD-7|Compulsive Sexual Behavior Inventory (CSBI-13)|DAS|DSCS|PCS|FGSIS|Edinburg"]

UPDATE:
[textarea name="variable_1" default=""]

SESSION ISSUES/TOPICS DISCUSSED
The following tropics/concerns were discussing in session: [checkbox name="cb8" value="|-------MOOD MANAGEMENT-------|Current symptoms/functioning|Symptom management|Management of depression symptoms|Management of anxiety symptoms|Management of depression and anxiety symptoms|Emotion dysregulation|Anger issues/mismanagement|Emotional expression concerns|Distress intolerance|--------TRANSGENDER ISSUES------|Gender dysphoria|Gender Identity Concerns|WPATH Standards of Care|Hormone therapy|Expectations for HRT|Gender expression|Gender expression and realistic expectations|Coming out as transgender|----------RELATIONSHIP DISTRESS-----|Relationship dissatisfaction|Conflict, argument, or regrettable incident with partner|Relationship intimacy concerns|Infidelity/affair concerns|Divorce issues|Relationship trust issues|Communication problems with partner|Relationship value conflict|-------ADJUSTMENT DISORDER-------|Adjustment to a stressor(s)|Adjustment to work changes|Adjustment to job loss|Adjustment to relationship changes|Adjustment to family life changes|Adjustment to a development event|------GRIEF LOSS-----|Death of a family member|Death of a friend|Grief reactions|Process past regrets|Processing grief through letter writing|-------ATTACHMENT ISSUES-----|Adult attachment style issues|Attachment anxiety and avoidance|Adult attachment anxiety|Fear developing intimate relationships|Fear of interpersonal rejection and/or abandonment|Adult Attachment Avoidance|Fear of intimacy|Excessive need for self-reliance|Reluctance for self-disclosure|Negative view of others|--------ABUSE OR STALKING----- |Power and control issues|Partner psychological abuse|Berating and/or humiliation by partner|Interrogation by partner|Restriction to go freely by partner|Obstruction of assistance by partner|Threats of physical harm by partner|Threats of sexual assault by partner| Restriction of access to economic and or financial resources by partner|Isolation from friends or family by partner|Partner stalking|Stalking concerns|Made to feel and think one is crazy by partner|-------INTERPERSONAL PROBLEMS------|Interpersonal conflict(s)|Conflict with friends|Conflict with family|Conflict with coworker(s)|Poor boundary setting|Difficulty saying no to others|Passive behaviors|Aggressive behaviors|-----SEXUALITY FUNCTIONING CONCERNS-----|Sexual functioning concerns|Sexual health concerns|Sexual behavior(s) of concern|Sexual boundaries|Sexual boundary violation|Distress related to sexual fantasies|Sexual orientation/identity concerns|Sexual orientation microaggressions|Internalized homophobia|Sexual relationship dissatisfaction|Sexual communication discomfort|Sexual scripts/sexual script adjustment|------DATING ISSUES-----|Dating and meaing of being single|Exploring different dating scenes|Obstacles to dating|Anxiety about dating|Stress with dating|Difficulty with online dating|Navigating dating and sexual boundaries|------FERTILITY HORMONE CONCERNS----|Fertility concerns|IVF-related stress|Pregnancy concerns|Delivery/post-delivery concerns|Peri menopause issues|menopause issues|Hormone therapy issues|Cancer and sexuality concerns|Age and sexuality concerns|------RACISM/SEXISM-----|Racism|Sexism|Sexual harassment|Occupational stereotypes/discrimination|-----BEHAVIORAL HEALTH ISSUES-----|Behavioral health issues|Self-Care|Hygiene issues|Sleep hygiene|Sleep difficulty|Weight management|Physical activity/exercise|------SUBSTANCE USE ISSUES----|Substance use concerns|Alcohol use concerns|Cannabis use concerns|Tobacco use concerns|-----TRAUMA ISSUES-----|Family of Origin dynamic|Past trauma event|Recent trauma event|Sexual trauma event|Past childhood neglect|Past childhood abuse|-----STRESSOR ISSUES-----|Stressors|Stressor/coping mechanism(s)|Familial relationship distress|Conflict with a family member|Work problems|Work-related stress|Negative work enviornment|Difficulty with work/life balance|Financial issues|Legal Issues|Housing issues|Parenting stress|-----MEDICAL HEALTH ISSUES-----|Medical/health concerns|Disease management|Medication concerns|Health anxiety|-----RELIGIOUS ISSUES-----|Religious/spiritual concerns"].


THERAPEUTIC INTEVENTIONS USED
Provider used the following interventions: [checkbox name="cb11" value="-----MOOD DISORDER INTERVENTIONS----|Active listening and feedback|Validated and normalized emotions|Supportive reflection|Open-ended questions|Socratic questioning|Self-disclosure|Bibliotherapy|Psychoeducation|Psychosexual education|Exploration of sexual history|----------COGNITIVE BEHAVIORL THERAPY----|Introduction to the CBT model|CBT therapy modalities|Cognitive challenging|Cognitive refocusing|Cognitive restructuring|Identification/modification of dysfunctional assumptions/biases|Identify distorted automatic thoughts|-----INTERPERSONAL INTERVENTIONS-----|Communication skills to address interpersonal concerns|Assertive communication skills|Exploration of interpersonal patterns|Discussed boundary setting|-----SEX THERAPY INTERVENTIONS------|Sex therapy interventions|Sensate Focus|Psychosexual education|Responsive desire|Respnsive desire vs. spontaneous desire|Willingness model|Sexual Staircase|Psychoeducation about the Dual Control Model|Brakes and Accelerators to sexual desire|Directed masturbation|Introduction to OMGYes.com|Discussion of sexual aids/toys/vibrators|Discussion of vaginal dilators|Exploration of self touch|Bibliotherapy|Mindfulness-based cognitive interventions|Introduction to the female sexual response cycle|Reviewed the female sexual response cycle|Review benefits of sexual aids|Discuss benefits of vibrators|Discuss the benefits of lubruation|Exploration of sexual diversity (e.g., Kink/BDSM)|--------GOTTMAN INTERVENTIONS----|Gottman Method Couple Therapy Interventions|Gottman Love maps|Psychoeducation on building fondness and admiration|Turning toward instead of away|Psychoeducation about increasing awareness of emotional bids|Identifying the Four Horsemen|Encouraging a gental approach|Psychological soothing for flooding|Establishing formal and informal ritual of connection|Process the aftermath of an argument or regrettable incident|Exlpore pattern of closeness and distance|Explore communication cycle|Observe and provide feedback on Couple communication|Exploration of family of origin /dynamics |-----DBT INTERVENTIONS----|DBT Skills|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 Training ----|-----PAIN MANAGEMENT-----|Pain management interventions|Motivation interviewing to assess readiness for change|------SUBSTANCE USE INTERVENTIONS------|Smoking cessation interventions|Alcohol use interventions|-----BEHAVIOR HEALTH INTERVENTIONS-------|Explored self-care strategies|Explored behavioral health interventions|Sleep hygiene interventions|Behavioral activation|Introduced SMART Goals|---STRESS MANAGEMENT INTERVENTIONS-----|Explored stress management interventions|Stress management interventions (e.g., deep breathing)|Stress management interventions (e.g., PMR)| Stress management interventions (e.g., deep breathing, PMR)|Subjective Unit of Distress (i.e., SUDs)|Introduced a decision matrix|Decision matrix|Practiced progressive muscle relaxation|Guided imagery|Diaphragmatic breathing"].

TREATMENT PROGRESS/PROGRESS TOWARDS TREATMENT GOALS
Client progress in achieving psychotherapy goals is best assessed as - [checkbox name="cb12" value="responding well to interventions|making some progress|slow/slight progress|fluctuating/intermittent progress|maintaining past gains|maintaining current goal focus|reprenting relapse|an increase in symptoms|a decrease in symptoms|a significant escalation  in symptoms|minimal|improving|stable"] - as evidenced by Client self-report, behavior, and engagement.


PLAN/HOMEWORK
[textarea name="variable_2" default=""]


MENTAL STATUS EXAM
Orientation: [select name="MSE_1" value="Alert and oriented X4|unable to assess due to cognitive impairment"]; Affect: [select name="MSE_2" value="Full range|Flat|Tearful at times|Flat, tearful & congruent with depressed & anxious mood|Appropriate to mood and thoughts|Inapporpriate to mood and thoughts|Restricted in range and mood congruent"]; Observations: [select name="MSE_3" value="WNL|Crying|Mild agitation when discussing stressor|Moderate agitation when discussing stressor|Occasional yawning|left room"]; Speech: [select name="MSE_4" value="WNL|Normal rate and rhythm, not pressured|Pressured at times|soft"]; Behavior: [select name="MSE_5" value="WNL|Left room to use bathroom"]; Thought process: [select name="MSE_6" value="WNL|Logical, linear, goal directed|circumstantial|Circumstantial but redirectable|Tangential"]; SI/HI: [select name="MSE_7" value="Not indicated|denied|SI endorsed/HI denied"]

FOLLOW-UP PLAN:
[checkbox name="cb14" value="Ct f/u in 1 week to assess mood/functioning, review homework, and goal setting|RCT in 1 week to assess relationship distress, review homework, and goal setting|Ct f/u in 2 weeks to assess mood/functioning, review homework, and goal setting|f/u in 2 weeks to assess mood/functioning, review homework, and goal setting|f/u in 1 month to assess mood/functioning, review homework, and goal setting|Client will contact Provider to schedule next session.|Provider will contact Client to schedule next session.|Late chart entry, transcribed from contemporaneous note, original in-session note deleted"].