RBF progress note new new

Client name: {FIRSTNAME} {LASTNAME} {{BIRTHDAY}}
Appointment: {APPOINTMENTDATE} from {APPOINTMENTSTARTTIME} to {APPOINTMENTENDTIME}
Exact start and stop times:
Session type: 90837-95, psychotherapy, 60 minutes, telehealth modifier
POS code: {POSCODE}
Diagnosis: 
Location: HIPAA compliant Google Meet/video
Client location at time of session: home address
Attendees: Client and therapist
Telehealth consent obtained: Yes

Note was created on XX/XX/23 from calendar and handwritten notes taken in session.

SUBJECTIVE/CHIEF COMPLAINT
Client expressed, [textarea name="problem" default=""] Client is a {AGE} year old [select name="gender" value="male|female|non-binary|transgender"] who presented initially for the therapeutic treatment for primary concern of [textarea name="primaryconcern" default="ADHD, anxiety, depression, PTSD, adjustment issues, marriage concerns." rows="2"] Client continues to report symptoms consistent with {DIAGNOSIS}. [checkbox name="Depression1" memo="Depression" value=""][checkbox name="Anxiety1" memo="Anxiety" value=""][checkbox name="Panic1" memo="Panic" value=""][checkbox name="ADHD1" memo="ADHD" value=""][checkbox name="PTSD1" memo="PTSD" value=""][checkbox name="Bipolar1" memo="Bipolar Disorder" value=""][checkbox name="Insomnia" memo="Insomnia" value=""][checkbox name="Alcohol1" memo="Alcohol Use" value=""][checkbox name="AdjustmentDisorder1" memo="Adjustment Disorder" value=""] [conditional field="Depression1" condition="(Depression1).is('')"] Depression is reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|little interest or pleasure in doing things|hopelessness|helplessness|sleeping too much|difficulty falling asleep|difficulty staying asleep|feeling tired or having little energy|poor appetite|overeating|feelings of guilt and inadequacy|irritability|poor concentration|psychomotor retardation|psychomotor agitation|suicidal ideation"][textarea memo="Additional information" rows="1"][/conditional] [conditional field="Anxiety1" condition="(Anxiety1).is('')"] Anxiety is reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|feeling restless/wound up|excessive worrying/difficulty controlling worry|difficulty concentrating|irritability|difficulty falling asleep|difficulty staying asleep|feeling tired or having little energy|muscle tension|headaches|feeling overwhelmed|changes in appetite"][textarea memo="Additional information" rows="1"][/conditional] [conditional field="Panic1" condition="(Panic1).is('')"] Panic symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|palpitations/racing heart|sweating|shortness of breath|chest pain/tightness|nausea/stomach cramps|numbness/tingling|fear of losing control|closed in feeling|feeling overwhelmed|heat sensations|trembling/shaking"][textarea memo="Additional information" rows="1"][/conditional] [conditional field="ADHD1" condition="(ADHD1).is('')"] ADHD symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"] Patient is reporting [checkbox value="no concerning progression of symptoms|inattention|careless mistakes|difficulty sustaining attention|problems following conversations|easily side tracked|difficulty organizing tasks/activities|avoidance and procrastination|forgetfulness|easily distracted by unrelated thoughts|fidgeting|inability to relax|excessive talking|difficulty waiting/reduced patience"][textarea memo="Additional information" rows="1"] [/conditional][conditional field="PTSD1" condition="(PTSD1).is('')"] PTSD symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|nightmares|flashbacks|intrusive memories/thoughts|avoidance|negative affect|loss of interest|isolation|difficulty experiencing positive emotions|irritability|easily annoyed|risky/self destructive behaviors|hypervigilance|heightened startle reaction|difficulty concentrating|difficulty falling asleep|difficulty staying asleep"][textarea memo="Additional information" rows="1"][/conditional] [conditional field="Bipolar1" condition="(Bipolar1).is('')"] Bipolar symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|elevated mood|irritable mood|increased self esteem|loss of sleep|racing thoughts|difficulty keeping up with thoughts|increased desire to speak|feeling more distracted|feeling more energetic|increased desire to engage in activities|agitation|impulsive behaviors|feeling more social/outgoing|increased sex drive|spending money|using drugs/alcohol"][textarea memo="Additional information" rows="1"][/conditional] [conditional field="Insomnia" condition="(Insomnia).is('')"] Insomnia symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|difficulty falling asleep|difficulty staying asleep|early morning awakening|nightmares|vivid dreams|thrashing in sleep|sleep walking|daytime sedation/fatigue|sleep talking|night terrors|confusion|sleep related eating|hallucinations going to sleep|hallucinations when waking up"][textarea memo="Additional information" rows="1"][/conditional] [conditional field="Alcohol1" condition="(Alcohol1).is('')"] Alcohol use symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of alcohol use|daily drinking|drinking more than anticipated|inability to cut down on drinking|cravings to drink|blackouts|hangovers|urges to drink|missing work due to drinking|drinking alone|drinking and driving|drinking to fall asleep|escalating alcohol use|tremors|nausea|vomiting|headaches|sweating|anxiety|racing heart|confusion|visual hallucinations|auditory hallucinations|seizures"][textarea memo="Additional information" rows="1"][/conditional] [conditional field="AdjustmentDisorder1" condition="(AdjustmentDisorder1).is('')"] Adjustment disorder symptoms are [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="marked distress that is disproportionate to the severity/intensity of stressor|significant impairment in social, occupational, and other areas of functioning|depressed/low mood|anhedonia|tearfulness|feelings of hopelessness|nervousness|excessive worrying|difficulty concentrating|feeling overwhelmed"][textarea memo="Additional information" rows="1"][/conditional]
Ongoing mental health treatment at this level is required to mitigate these symptoms and help client achieve desired goals for therapy.

Changes in medication: [text name="medication" default="none reported."]

Care coordination: Client discussed no need for care coordination/release of information at this time.

To address client's symptoms and achieve therapeutic goals, the main themes of the session were: [checkbox name="Symptomsmanagement" memo="Symptoms/Management" value=""] [checkbox name="ADHD" memo="ADHD" value=""] [checkbox name="Behavioralhealthissues" memo="Behavioral health issues" value=""] [checkbox name="Substanceuse" memo="Substance use" value=""] [checkbox name="Adjustment" memo="Adjustment" value=""] [checkbox name="Griefloss" memo="Grief/loss" value=""] [checkbox name="Stressors" memo="Stressors" value=""] [checkbox name="Themes" memo="Other Themes" value=""] [checkbox name="Relational" value="" memo="Relational Themes"][checkbox name="Trauma" value="" memo="Trauma Themes"][checkbox name="Identity" value="" memo="Identity Themes"][checkbox name="DailyLife" value="" memo="Daily Life Themes"]
[conditional field="Symptomsmanagement" condition="(Symptomsmanagement).is('')"][checkbox value= "Current symptoms/functioning|Symptom management|Management of depressive symptoms|Management of anxiety symptoms|Emotional dysregulation|Distress intolerance|Anger issues|Mood management|Impacts of symptoms|dealing with panic and anxiety states|exploration and coping with depression and sadness|awareness and exploration of feelings of powerlessness, hopelessness and helplessness|awareness and exploration of possible psychosomatic reactions"][/conditional] [conditional field="ADHD" condition="(ADHD).is('')"][checkbox value= "ADHD symptoms/diagnosis|ADHD treatment/medications|Self-esteem|Management of executive dysfunction"][/conditional] [conditional field="Behavioralhealthissues" condition="(Behavioralhealthissues).is('')"][checkbox value= "Self-care activities|Sleep difficulty/concerns|Nutrition/eating habits|Physical activity/exercise|Daily scheduling|Energy levels"][/conditional] [conditional field="Substanceuse" condition="(Substanceuse).is('')"][checkbox value= "Substance use concerns|Alcohol use concerns|Cannabis use concerns|Tobacco use concerns|Relapse prevention"][/conditional] [conditional field="Adjustment" condition="(Adjustment).is('')"][checkbox value= "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|transition to adulthood and adult responsibilities|strain of mid-life transitions|late-life adjustment and coping with age-related changes|adjustment to recent motherhood|adjustment to recent fatherhood|parenting anxieties and concerns|adjustment to separation from child/children|adjustment to new demands in life situation|adaptation to physical illness"][/conditional] [conditional field="Griefloss" condition="(Griefloss).is('')"][checkbox value= "Death of a family member|Death of a friend|Grief reactions|Processing past regrets|Processing grief|Processing a death/loss"][/conditional] [conditional field="Stressors" condition="(Stressors).is('')"][checkbox value= "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/issues"][/conditional] [conditional field="Themes" condition="(Themes).is('')"][checkbox name="Themes2" value= "expression of stressful experiences|exploration of low self-esteem and poor confidence/working towards improved self-esteem and confidence|coping with exhaustion and burn out in work/educational activities|awareness and exploration of perfectionistic tendencies|issues of impulse control|exploration and working through guilt and related anxieties|exploration of life experiences and self-understanding|development of self-care|exploration and evaluation of target behaviors and areas of concern|discussion of medication and its impact|exploration and discussion of recent homework assignments|review of the therapeutic work to date|exploration of therapeutic goals and aims|revision of therapeutic goals and aims|recent progress being made in the therapy|obstacles experienced in therapy|the impact of teletherapy on the therapy experience"][/conditional] [conditional field="Relational" condition="(Relational).is('')"][checkbox name="Theme_Relational" value= "relational difficulties|recent relational conflict|coping with relational frustrations|struggles with social anxiety|coping with anger and envy in interpersonal relationships|coping with feelings of rejection in interpersonal relationships|difficulties with boundaries in interpersonal relationships|securing appropriate boundaries|crisis situation in family|conflict with family members|working through interpersonal/family experiences|interpersonal difficulties with spouse/partner|sexual difficulties and/or concerns|exploration of family life|exploration of relationship with father|exploration of relationship with mother|exploration of relationships with sibling(s)|exploration of relationships with children|exploration of parenting concerns|exploration of relationships with friends|exploring relational concerns and issues in the workplace|coping with conflict with authorities at work|exploring relational concerns and issues in school|exploration of positive interpersonal experiences|recent positive relational experiences|reparation of broken and/or strained interpersonal relationships|exploration of recent conflict with friend(s)|exploring forgiveness and reparation in interpersonal relationships|addressing issues related to trust in interpersonal relationships"][/conditional] [conditional field="Trauma" condition="(Trauma).is('')"][checkbox name="Theme_Trauma" value= "Family of origin dynamics|Past trauma event|Recent trauma event|Sexual trauma event|Childhood trauma|Past childhood abuse/neglect|Past distressing memory|expression of stressful experiences|exploration and discussion of traumatic experiences|exploration of childhood traumas and neglect|exploration of multiple traumatic events and cumulative trauma in childhood/adolescence|exploration of impact of sexual abuse experiences experienced in childhood/adolescence|exploration of emotional neglect experienced during childhood/adolescence|exploration of transgenerational traumas|exploration of vicarious traumatic experiences|exploration of health concerns and illness|exploration of end of life anxieties, fears, and concerns|expression and exploration of experiences of victimization|exploring and addressing traumatic loss|exploration of the traumatic experience of the pandemic|coping with the traumatic nature of the pandemic|exploration of traumatic isolation and disconnection from others|exploration of experienced cumulative trauma|exploration of racial stress and racial trauma|exploration of traumatic experiences of discrimination|exploration of sexual assault experience(s)|coping with and managing recent sexual assault experience|expression and exploration of recent traumatic injury|exploration and discussion of collective/cultural traumatic experiences|coping with experienced assault and/or physical threat or violence|exploration of traumatic experiences endured during military service|addressing and exploring post-traumatic reactions and experiences|exploration and coping with a recent serious medical diagnosis|exploration and discussion of traumatic experiences impacting the couple|exploration and discussion of traumatic experiences impacting the family|continued exploration of the impact of early life on current identity"][/conditional] [conditional field="Identity" condition="(Identity).is('')"][checkbox name="IdentityTheme" value= "exploration of low self-esteem and poor confidence|exploration of distorted body image|conflicts and concerns regarding ethnic/cultural identity|exploration of anxieties regarding gender and/or sexuality identity|exploration of conflicts regarding masculinity and/or issues of male sexuality|exploration of conflicts regarding femininity and/or issues of female sexuality|exploration of conflicts and anxieties regarding masculinity|exploration of conflicts and anxieties regarding femininity|exploration of obstacles to identity development in adolescence|exploration of adolescent identity concerns|expression and exploration of crisis of identity|working towards integration of adult identity|exploration of mid-life identity concerns and meaning|exploration of late-life identity formation and concerns|life-review as part of later-life identity consolidation|difficulties with boundaries and self-assertion|exploration of feelings of lack of entitlement|exploration and working through of 'false-self' states and their relationship to early life experiences|exploration of distress related to body-dysmorphic perceptions|exploration of distress and/or concerns related to transgender identity|exploration of distress and/or concerns related to disclosure of sexual identity|exploration of uncertainties surrounding gender and/or sexuality|exploration of experienced racial/cultural identity|exploration and development of professional/work identity|communication and discussion regarding issues of sexuality and/or gender identity within the family"][/conditional] [conditional field="DailyLife" condition="(DailyLife).is('')"][checkbox name="DailyLife2" value=  "management and coping with daily life|structuring of daily life and making plans for the future|coping with day to day organizational difficulties|working toward improved healthy life style|development of greater self-assertion and effective interpersonal communication|development of hobbies and leisure activities|identifying obstacles to mental and emotional wellbeing"][/conditional]

OBJECTIVE
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. Client is oriented x3, mental status and functioning appear to be WNL. Client's observed affect is [textarea name="MSE" default="full, flat, blunted, labile, tearful, appropriate, inappropriate, restricted and client reported their mood to be euthymic, depressed, anxious, irritable, angry, sad, elevated. Client's observed behavior and appearance both appropriate. Client denied A/V hallucinations."]

Measures completed and scores: 
[checkbox name="00" value="None"][checkbox name="PHQ" value= "PHQ9"][conditional field="PHQ" condition="(PHQ).is('PHQ9')"][text name="score1" default=""][/conditional][checkbox name="GAD" value= "GAD7"][conditional field="GAD" condition="(GAD).is('GAD7')"][text name="score2" default=""][/conditional][checkbox name="PCL" value= "PCL5"][conditional field="PCL" condition="(PCL).is('PCL5')"][text name="score3" default=""][/conditional][checkbox name="DES1" value= "DES"][conditional field="DES1" condition="(DES1).is('DES')"][text name="score4" default=""][/conditional][checkbox name="SCARED1" value= "SCARED"][conditional field="SCARED1" condition="(SCARED1).is('SCARED')"][text name="score5" default=""][/conditional][checkbox name="ASRS1" value= "ASRS1.1"][conditional field="ASRS1" condition="(ASRS1).is('ASRS1.1')"][text name="score6" default=""][/conditional]

ASSESSMENT
Suicidality/Homicidality: [checkbox name="safety" value="SI/HI denied|Endorsed passive SI|Endorsed active SI with a method but without plan or intent to act|Endorsed recent suicide attempt|Endorsed nonsuicidal self-injury|Endorsed homicidal ideation but without plan or intent to act|Denied homicidal ideation"]
Risk factors: [checkbox name= "risks" value= "No additional risk factors present, no contrary clinical indications present, therapist will continue to monitor.|Hx of suicidality|Hx of non-suicidal self injury|Alcohol use|Drug use"]

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

From the client’s report and therapist observation, client 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.
Ct requires ongoing treatment of the diagnosed condition to: [select name="medical" value= "Address symptoms and achieve symptomatic relief.|Improve functioning in one or more life domains.|Maintain progress/prevent decompensation.|Prevent higher level-of-care/avoid hospitalization.|Current level of treatment is necessary as the client continues to meet diagnostic 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.|Address complicated issues related to diagnosis(es) and clinical presentation.|EMDR Protocol.|Client reports subjective level of distress/acute issues.|Addressing new or emergent symptoms.|Clinical symptoms cause functional impairment in ability complete activities of daily living,
occupational functioning, and/or social functioning that is not characteristic when the person is not
symptomatic."]

[comment memo="Client Report"][textarea name="assessment" default="Client endorsed/expressed/stated...."] 
[textarea name="therapistinterventions" default="Therapist utilized open ended questions to elicit more information regarding thoughts/feelings/beliefs related to... Therapist worked with client to identify and label specific emotions associated with situation and encouraged client to process identified thoughts and feelings.."] Therapist provided supportive listening techniques, interactive feedback, and encouragement throughout.
[textarea name= "therapistinterventions2" default="Therapist normalized and validated ct's feelings, {reinforced use of healthy coping strategies/positive self talk/assertive communication, worked with client to develop new coping strategies, collaborated with client to problem solve presenting issues/barriers to accomplishing goals, provided psychoeducation on presenting concerns}."]
[textarea name= "therapistinterventions3" default="Additionally, therapist assisted client with {self advocacy/communicating needs, identifying pros/cons to change, identifying negative thinking patterns, identifying source of distorted thoughts, identifying hobbies/values, identifying patterns and consequences of avoidance, identifying/exploring triggers, identifying strengths and support system, identifying and setting goals, identifying how current thoughts/beliefs influence their mood and behaviors, identifying/exploring situations that are anxiety provoking, exploring impact of trauma on their life, exploring background/family of origin, exploring effects of childhood experiences, exploring history of..., exploring issues around trust, exploring issues of unresolved grief/loss, exploring patterns of conflict within the family/relationship, exploring current family dynamics, practicing cognitive challenging/reframing, practicing relaxation techniques/mindfulness practices/grounding techniques}."]
[checkbox name="moreinterventions" value="" memo="expand more interventions"][conditional field="moreinterventions" condition="(moreinterventions).is('')"] Additional in session interventions provided include:
[comment memo="Anxiety TX"] [checkbox name="interventions2" value="assessed reasons for symptoms of anxiety|explored triggers/situations|assisted client with analyzing fears in logical manner|assisted client with developing insight into worry/avoidance|explored source of distorted thoughts|recommended medication evaluation to address symptoms|explored benefits of taking medication|educated client on relaxation skills/techniques|explored problem solving strategies|validated/reinforced use of coping strategies|planned and reviewed healthy methods of distraction|taught and practiced progressive muscle relaxation|taught and practice deep breathing exercises|engaged client in guided imagery|assisted client with exploring ways to engage in mindfulness practices|identified and explored relaxation techniques|identified and practiced challenging negative automatic thoughts that perpetuate symptoms of panic|identified cognitive distortions related to panic symptoms|engaged in interoceptive exposure activities|provided psychoeducation on 'window of tolerance'|explored distress tolerance skills|encouraged medication evaluation|practiced grounding techniques"]
[comment memo="Assessment"] [checkbox name="interventions3" value="psychoeducation on psychotherapy|rapport building|assessed client's symptoms and history"][comment memo="ADHD"] [checkbox name="interventions4" value="assisted client with identifying positive aspects of self|explored and assigned positive affirmations to practice|encouraged and reinforced use of positive self-talk|exploration of time management skills|exploration of organizational skills|exploration of prioritization skills|encouraged outside reading on ADHD/neurodivergence|provided education about ADHD/neurodivergence|assisted client with identifying strengths/positive qualities|exploration of social constructs"] [comment memo="CBT"] [checkbox name="interventions5" value="introduced the CBT model|assisted client in identifying and modifying dysfunctional assumptions/biases|reviewed common cognitive distortions/negative thinking patterns|identified cognitive distortions/negative thinking patterns using examples from client's life|practiced cognitive restructuring/challenging|reviewed 'feelings wheel' tool|assisted client in exploring and developing emotional awareness|assisted client with exploring and identifying emotional reactions|developed alternative thoughts and beliefs|assisted client with identifying how client's current thoughts/beliefs influence their mood and behaviors"][comment memo="Interpersonal"] [checkbox name="interventions6" value="explored how fear of disappointing others affects functioning|provided education on the benefits of assertiveness skills|provided education on and practiced assertiveness skills|reinforced/encouraged assertiveness|encouraged use of 'No'|provided education on healthy boundaries|practiced/reinforced/modeled use of healthy boundaries|encouraged decision making|assisted client with self advocacy/communicating needs|assisted client with identifying opposite actions from emotional urges|explored and identified styles of communication that prevent positive interactions"][comment memo="General Interventions"] [checkbox name="interventions7" value="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|reviewed family of origin hx/dynamics|role playing|modeled behaviors|collaborated with client to problem solve presenting issue|assisted client with identifying/labeling emotions|encouraged client to process thoughts and feelings related to problem|identified negative coping and defense mechanisms|provided psychoeducation on presenting concerns|provided resources/literature related to problem|encouraged client to review resources/literature|worked with client to identify barriers to treatment/progress|reviewed homework|reviewed client's treatment plan and discussed progress towards goals|assisted client with identifying and setting goals|administered clinical assessments and discussed meaning/results|explored and discussed termination|planned for termination|reviewed treatment frequency|explored self care strategies|assisted client in identifying hobbies/values|assisted client in identifying and practicing positive self affirmations|encouraged hygiene/grooming practices|identified and planned enjoyable activities|reviewed healthy methods of de-escalation"][comment memo="Insomnia"] [checkbox name="interventions8" value="provided psychoeducation on sleep hygiene|explored negative associations with sleep/bed|explored and practiced relaxation strategies|assisted client with problem solving barriers to implementing good sleep hygiene|recommended medication evaluation to assist with managing symptoms"][comment memo="MI/SUDS"][checkbox name="interventions9" value="elicited change talk|elicited alternative behaviors|assisted client with identifying pros/cons to change|assessed ct's readiness for change|explored drug/alcohol history|explored and identified negative consequences of substance use/abuse|educated on consequences of substance use on mental health|encouraged client to remain open to discussion around denial/acceptance|encouraged participation in AA/NA|supported client's participation in AA/NA|facilitated and explored understanding of risk factors|explored positive aspects of sobriety|encouraged exercise and social activities that do not include subtances|reinforced working on sobriety|explored and reframed negative self-talk|assessed stress management skills|identified stress management skills|developed relapse prevention plan|explored cravings/identified triggers"][comment memo="Couples and families"] [checkbox name="interventions10" value="explored and identified patterns of conflict within the family|provided education on conflict resolution|explored familial communication patterns|facilitated family communication|identified how family patterns of conflict and communication are played out|explored and identified maladaptive patterns of communication learned from family of origin|facilitated healthy expression of feelings/concerns|reinforced use of healthy expression of feelings|identified/reinforced family strengths|explored roles in the family|assisted with defining roles in the family|explored areas of strength that may be used to parent|provided education on/practiced/modeled parenting techniques|processed the aftermath of argument/disagreement|explored activities to enhance feelings of positive connection"][comment memo="Trauma/Grief"] [checkbox name="interventions11" value="explored trauma history and impacts on client's life|explored and identified potential reasons for behaviors/symptoms|identified patterns of avoidance|identified consequences of avoidance|provided psychoeducation on role avoidance plays in maintaining PTSD symptoms|provided psychoeducation on PTSD/symptoms|provided psychoeducation on impacts of trauma on the brain|identified and processed issues around grief/loss|explored and identified triggers|identified alternative behaviors/coping skills that have helped in the past|explored and identified strengths and support system|planned activities to cope with reminders of the loss|explored secondary losses|explored the meaning of the loss"] [checkbox name="EMDR" value= "EMDR"][conditional field= "EMDR" condition="(EMDR). is('EMDR')"][checkbox name="phases" value= "Phase 1|Phase 2|Phase 3/Assessment|Phase 4/Desensitization| Phase 5/Installation|Phase 6/Body Scan|Phase 7/Closure|Phase 8/reevaluation|Safe/Calm Place|Future Template|Resource Development and Installation|Container Exercise|Spiral Technique|Recent Event Protocol|Float Back Exercise"][checkbox name= "EMDR2" value= "NC"][text name="NC" default=""][checkbox name= "EMDR3" value= "PC"][text name="PC" default=""][checkbox name= "EMDR4" value= "VOC Starting"][conditional field="EMDR4" condition="(EMDR4).is('VOC Starting')"][select name="EMDR5" value="select one|1|2|3|4|5|6|7"][/conditional][checkbox name= "EMDR6" value= "VOC Ending"][conditional field="EMDR6" condition="(EMDR6).is('VOC Ending')"][select name="EMDR7" value="select one|1|2|3|4|5|6|7"][/conditional][checkbox name= "EMDR8" value= "SUDS Starting"][conditional field="EMDR8" condition="(EMDR8).is('SUDS Starting')"][select name="EMDR9" value="select one|0|1|2|3|4|5|6|7|8|9|10"][/conditional][checkbox name= "EMDR10" value= "SUDS Ending"][conditional field="EMDR10" condition="(EMDR10).is('SUDS Ending')"][select name="EMDR11" value="select one|0|1|2|3|4|5|6|7|8|9|10"][/conditional][/conditional][/conditional]

Progress:
SESSION GOALS: [checkbox name="Goals" value="symptom reduction|skill acquisition|improve functioning|improve health|maintain positive gains|reduce ineffective behaviors|safety planning|treatment review|termination/discharge|xxxxxx"][text name="session_goals" default=" "]
Treatment goals addressed this session include [textarea name="goals" default="reducing overall level, frequency, and intensity of anxiety, improving/developing coping skills, reducing symptoms of depression, reducing symptoms of PTSD, improving overall mood, coping with routine life stressors, improving executive functioning skills, improving quality of interpersonal relationships, resolving issues related to traumatic event, processing grief/loss, learning effective communication strategies." rows="6"] Client was actively engaged throughout the session and responded well to the intervention offered. Treatment continues to show good evolution and development.
[checkbox name="more_RTI" value="" memo="expand more progress and RTI options"]
[conditional field="more_RTI" condition="(more_RTI).is('')"]Client's progress and response is best described as: [checkbox name="Progress" value="Fluctuating/intermittent progress apparent. Although the current concerns have 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 is on maintenence and relapse prevention, with client moving toward termination via reduced session frequency.|A significant reduction in symptoms and engaged in the therapeutic process.|Near completion of treatment.|Some increase in symptoms.|Significant increase in symptoms.|No notable change.|Slight progress.|Fluctuating/intermittent progress."] [text name="moreprogress_text" default=" "][/conditional] [comment memo="Client strengths"] The client demonstrates [checkbox name= "progress2" value= "progress with self-understanding and self-insight|improved capacity for self-care and life management|improvements in the areas of family and relational functioning|improvements in the areas of occupational functioning and achievement|improvement in containing harmful acting out behavior|improvement in self-esteem and confidence"] Client also exhibits [textarea name="strengths" default="regular utilization of effective coping strategies, improved insight into their responses and natural/conditioned ways of thinking, increased capability to appropriately identify and express emotions, improved capacity for emotion regulation, improvement in tolerance for frustration, increased capability to tolerate painful feelings, increased capacity to show compassion for themself, improvement in ability to manage and respond appropriately to symptoms, positive adjustments to their mindset and former distortions."] [comment memo="Client challenges"] Client continues to experience challenges with [textarea name="challenges" default="consistently recognizing/labeling emotions, managing and responding appropriately to symptoms, regularly utilizing coping skills, regularly utilizing effective communication skills, executive functioning skills, tolerating frustration, cognitive distortions, emotional/affect regulation, sleep, social functioning/relationships, practicing personal hygiene/self care, anhedonia, avoidance, procrastination, intrusive thoughts/memories, excessive worrying, depressed mood, negative cognitions,"] which continue to negatively and significantly impact the client's quality of life. In order to alleviate/reduce symptoms of [textarea name="necessary" default="depression, anxiety, trauma, mood disorder, ADHD" rows="2"] and improve functioning, it is necessary for client to remain engaged in current level of care/services. 

PLAN
Changes in diagnosis or treatment plan: [checkbox name="Plan" value="None/treatment to continue as indicated|increase/decrease session frequency|move toward discharge|discharge|referral to xxxxxx|higher level of care needed|client/guardian will call to schedule follow up appointment"]

Planned actions for future sessions: Therapist will continue to utilize [checkbox name="ebt" value= "CBT|EMDR|CPT|PE|Mindfulness-based|Behavioral activation|TF-CBT|Solution-Focused Therapy|DBT skills"]
Therapist will also review [checkbox name="checkon" value="homework/outside assignment|recent stressors/emotional experiences|symptom intensity/frequency|goal achievement/outcomes"] with client at next visit.
[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.|Higher level of care needed, referred to xxxxxx for assessment and indicated treatment before returning to outpatient treatment."]

Date of next session: [text name="date" default="XX/XX/23"]

Homework: Ct agreed to [checkbox name="homework" value="reflect on psychoeducation topics/materials covered in today's session|engage in journaling/reflective note taking as discussed in session|create daily routine to encourage self care, behavioral activation, and organization|consistently commit to daily routine/behavioral activation schedule|establish healthy boundaries with friends/family using techniques discussed and roleplayed during session|discuss healthy communication skills with family/friends, as outlined in communication skills work complete in session|utilize CBT skills (reframing/challenging/replacing negative thoughts)|engage in self directed exposure therapy/incremental training around specific anxieties as discussed in session|decrease catastrophic thinking by engaging in behavioral experiments and tracking progress|engage in mindfulness/stress reduction techniques as practiced in therapy (deep breathing, meditation, guided imagery)|experiment with at least one new self care activity this week and reflect in journal/planner|practice distress tolerance skills as rehearsed in therapy|implement coping skills consistently when dysregulated|tracking mood, and triggers for mood fluctuations|following safety plan if in crisis|track success and progress toward goals|devise a regular and adequate eating schedule, a pattern of adequate sleep and relaxation, as well as regular cardiovascular exercise"][text name="homework" default=""]

Client's overall prognosis is [textarea name= "prognosis" default="good, fair, guarded, poor." rows="2"]