RR Checkbox Note FINAL

RISK ASSESSMENT
Client participated in assessment for safety/risk factors and/or created safety plan. Client endorses [checkbox name="variable7" value="No current suicide or homicide ideation|current suicide/homicide ideation|past suicide/homicide ideation|current suicide/homicide ideation with means but without plan or intent to act|past suicide/homicide attempt|recent suicide/homicide attempt|non-suicidal self-injury|death ideation"].Additional details:[textarea name="variable_1" default="Enter further details regarding SI/HI here"]


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MEDICATION
[checkbox name="meds" value="Client denies current prescription of medication(s).|Client reports no changes to prescribed medication(s).|Client reports changes to prescribed medication(s).|Therapist and clt did not discuss medication. Will continue to explore medication changes in future sessions|Client notes"] [textarea name="medchanges" default="Enter med changes and notes here" rows="2"]

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SYMPTOMS AND SUBJECTIVE

Client reports experiencing symptoms and/or has complaints about[checkbox name="symptoms4" value="anxiety|intrusive thoughts|rumination|fear of embarrassing self|panic/panic attacks|intense fear/intense discomfort|worry about future panic symptoms/attacks|difficulty controlling worry/excessive worrying|worry about job responsibilities|worry about health|worry about finances|worry about future of relationship|fear |depressed mood|sadness|loss of interest in pleasurable activities|tearful or crying spells |fatigue/low energy|difficulty sleeping|sleeping too much|trouble falling asleep|appetite changes |difficulty concentrating|low motivation|poor performance|isolation from others|loneliness|low self esteem|low self-confidence|lack of self care |muscle tension|hopelessness|impulsivity|hyper vigilance|grief|interpersonal conflicts |irritability|binging/purging|life transitions |role confusion|shame|OCD symptoms or behaviors |poor impulse control|physical pain|restlessness|trauma"]

Client cites [textarea name="updates" default="session notes here"].

Client discusses [checkbox name="variable4" value="symptom management|management of depression symptoms|management of anxiety symptoms|self-esteem |ADHD|friendships|childhood/family of origin |family of spouse|familial relationship distress |emotional dysregulation|anger issues|distress intolerance|adjustment to stressor(s)|grief/loss |relationship distress|relationship dissatisfaction |relationship argument/incident|relationship intimacy concerns|interpersonal ineffectiveness/conflict|boundary setting|conflict with peers |conflict with family|conflict with coworkers(s) |self-care/hygiene issues|sleeping issues|physical activity/exercise|substance use concerns|alcohol use concerns|cannabis use concerns|nicotine use concerns|trauma|coping mechanisms|employment issues|financial issues|legal issues|housing issues |parenting stress|medical/health concerns |religious/spiritual concerns|CPS Involvement"] [textarea name="discuss" default="Enter other topics discussed here" rows="2"].

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OBJECTIVE
Client consented to meet via [select name="mode" value="via TherapyNotes Telehealth Platform|via secure telehealth|in person"]. 

Encounter type: [checkbox name="variable_1" value="Individual|Couples|Family|Extended Session|Crisis Session|Collateral WITHOUT client present|Individual WITH collateral"][textarea name="encounter" default="Specify who and context here. (I.e. mother attended  First/last 10 mins of session for coordination of care" rows="2"].

Client location:[text name="location" default="Enter location"]

Major Themes:[checkbox name="variable16" value="Identity/Role Confusion|conflict in relationship| work problems|school problems|stressors/coping methods|childhood/family of origin|traumatic events|substance use|goals/treatment planning |grief processing|conflict with peer group|financial worries|housing instability |recovering from divorce/breakup|new medical diagnosis|cognitive impairment/functioning|sleep issues |biopsychosocial assessment "][textarea name="themes" default="Enter other themes discussed here" rows="2"].

Therapist [checkbox name="variable17" value="reviewed of homework|discussion of progress towards goals|provided psychological assessments|assisted with boundary setting|provided active and empathetic listening toward the client's thoughts and feelings|engaged using open-ended questions|stated normalization/validation of thoughts and feelings|conducted therapeutic rapport building|provided encouragement and reassurance|reviewed family history/dynamics|provided role-play exercises|assisted client in problem-solving|processed client's thoughts and feelings|identified negative coping mechanisms|provided psychoeducation about mindfulness and meditation|provided relaxation skills|provided psychoeducation|identified and challenged cognitive distortions|practiced cognitive restructuring|reviewed self-care activities|stated positive affirmations|identified and/or reviewed positive coping skills|reviewed and practiced effective communication skills and assertiveness techniques|elicited change talk|explored and reviewed effective parenting strategies|processed the aftermath of an argument or incident|explored patterns of closeness and distance in relationships|explored couple's communication cycles|observed and provided feedback on couple's communication and interactions|provided DBT/emotion regulation skills|provided DBT/distress tolerance skills|provided DBT/interpersonal effectiveness skills|provided CBT approaches|provided psychoeducation on improvement of sleeping habits|created a behavioral activation list with client|explored trauma and impacts on client's life|explored patterns of conflict|explored potential reasons for behaviors/symptoms|identified and processed issues around grief/loss|identified triggers|identified alternative behaviors/coping skills that have helped in the past|identified and explored strengths and/or support system|utilized person-centered modalities|utilized EFT modalities|utilized ACT modalities|utilized motivational interviewing (MI) approaches"][textarea name="sx" default=" Add additional here"  rows="2"]


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ADDITIONAL NOTES / ASSESSMENT

This note was created on the date and time of session [text name="DT" default="Enter date/time"] and manually entered into the system on the date signed."

Medical Necessity:Diagnostic impression is consistent with diagnosis due to continuation of meeting diagnostic criteria. [checkbox name=mn" value="Rapport building|Frequency History of Trauma|Client Crisis/Acute Issues|Time Necessary to address and contain intense emotional content| Preventative measures to avoid higher level of care|Necessary for the therapeutic intervention utilized in session|Addressing new or re-emerging symptoms|Limited healthy support network|Client is unable to share content with others in support system due to nature of topic|EMDR Protocol being utilized|Bi-weekly Sessions|Monthly sessions to maintain acquired skills|Symptoms are impacting multiple domains of life|IFS protocol being utilized|Assessment and stabilization|Significant trauma history necessitates additional time for disclosure and containment|Address complicated issues related to diagnosis and clinical presentation|Grounding needed for symptoms that emerged during session |Reviewed homework|Client requested longer session time due to decreased frequency of sessions|Prevent escalation to intensive level of care|Exposure therapy for post-traumatic stress disorder, panic disorder, obsessive compulsive disorder or specific phobia|Unexpected complication resulting from pharmacotherapy|Parental involvement|Building a Healthy Support Network|BPD diagnosis requiring DBT sessions|Clinical symptoms impacting functional impairment causing client the inability to complete activities of daily living, occupational and/or social functioning"]


Session was congruent to treatment plan goals: [checkbox name="tx" value="1|2|3|4|5|6|7|8"]

Client displays strengths including:[checkbox name="variable9" value="awareness of emotions|motivation to progress in treatment|utilization of positive coping techniques|ability to express emotions/feelings|willingness to be vulnerable and ask for help from others at critical times|awareness and honesty around negative coping techniques|the ability to tolerate painful or uncomfortable feelings|openness to trying new, positive behaviors|seeking positive relationships|having compassion for self"][textarea name="strength" default="Enter other strengths discussed here" rows="2"].

Client displays barriers including:[checkbox name="variable10" value="social stigma|fear|financial concerns|time commitments|fear of incompetence |fear of self-disclosure|fear of reliving painful emotions|trust issues|lack of rapport |substance use|isolation"][textarea name="barriers" default="Enter other barriers discussed here" rows="2"].


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PLAN 
Therapist will [checkbox name="plan" value="meet with client in 1 week to assess mood/functioning, and implementation of treatment plan goal(s)|meet with client in 2 weeks to assess mood/functioning, and implementation of treatment plan goal(s)|meet with client in 1-2 weeks to assess mood/functioning, and implementation of treatment plan goal(s)|meet with client in 3 weeks to assess mood/functioning, and implementation of treatment plan goal(s)|meet with client in 1 month to assess mood/functioning, and implementation of treatment plan goal(s)|meet with client in 1 month to determine need for continued treatment or termination|begin termination process with client|client will contact therapist to schedule next session|Therapist will contact client to schedule next session|Date of next session"]  [date name="variable_4" default="date"].  Client agreed to this plan.