Session Note – Adult

Presenting Problem(s)/Session Goal(s):
_____ presented for this [select name="sessiontype" value="individual|family"]    session seeking support for [checkbox name="variable1" value="anxiety|depressed mood|sadness|relationship conflict|processing emotions related to past experience| loss of interest in pleasurable activities|tearful or crying spells|dysregulation|fatigue/low energy|difficulty sleeping|trouble falling asleep|appetite changes|difficulty concentrating|low motivation|poor academic/work performance|isolation from others|loneliness|low self-esteem|suicidal ideation|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|muscle tension|difficulty controlling worry/excessive worrying|worry about job responsibilities|worry about health|worry about finances|panic attacks|fear|hopelessness|impulsivity|hypervigilance|grief|worry about future of relationship|low self-confidence|interpersonal conflicts|irritability|emotional instability"]. Client reports doing [select name="presentation" value="okay|same as last week|better than last week|worse compared to last week|not so good"].
[checkbox name="Intervention" value="___presented via Telehealth. Therapist confirmed location and commented on secure space to ensure confidentiality."] 
To address client's symptoms and achieve therapeutic goals, the focus/themes of session for today include:[checkbox name="SessionFocus" value="ADHD| gender/sexuality| attachment issues| anxiety|depression| trauma| bipolar symptoms| relationship stress| interpersonal adjustment| grief/loss| stressors| family conflict|  managing intense emotions| communication challenges| problem-solving| perspective-taking| increasing motivation|identifying negative cognitions|coping strategies| symptoms/management"]

Mental Status Exam: 
[checkbox name="MSE" value="Mental status was within normal limits in all domains, including appearance, activity level, speech, affect, mood, eye contact, behavior, orientation, memory, insight, and thought processes."] 
[checkbox name="Appearance" value="Appearance:|stated age|younger than stated age|older than stated age|neat|disheveled|clean|inappropriate dress|appropriate dress"]
[checkbox name="Mood" value="Mood:|happy|depressed|irritable|sad|good|angry |fantastic |broad|restricted "]
[checkbox name="Affect" value="Affect:|euthymic|angry|anxious|depressed |elated|irritable|euphoric "]
[checkbox name="GeneralBehavior" value="General Behavior:|engaged and cooperative|in distress|withdrawn|agitated|appropriate eye-contact|avoids eye-contact |responsive|takes initiative "]
[checkbox name="ThoughtsCognitions" value="Thoughts/Cognitions:|alert and oriented|clear insights|poor insights|logical and sequential |goal directed|illogical |blocking|distractible|flight of ideas|tangential"]
[checkbox name="variable7" value="Client participated in assessment for safety/risk factors. Client endorses |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"].
[checkbox name="variable2" value="Client is not currently prescribed medications.|Client reports no changes to prescribed medication(s).|Client reports changes to prescribed medication(s).|Notes"]

Intervention:
Therapist [checkbox name="variable17" value="reviewed of homework|reviewed patient's treatment plan and had discussion of progress towards goals|provided psychological assessments|assisted with boundary setting|provided active and empathetic listening toward the patient'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 patient in problem-solving|processed patient'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|introduced emotion regulation skills|practiced distress tolerance skills|supported client to practice interpersonal effectiveness skills|provided CBT approaches|provided psychoeducation on |improvement of sleeping habits|coping strategies|created a behavioral activation list with patient|explored trauma and impacts on patient'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|supported client using    solutions-focused prompts"].

Response to Intervention    
Client discussed [checkbox name="variable4" value="symptom management|management of depression symptoms|management of anxiety symptoms|self-esteem|ADHD symptoms|friendships|childhood/family of origin|emotion dysregulation|anger issues|distress intolerance|an adjustment to a stressor(s)|grief/loss|relationship distress|relationship dissatisfaction|relationship argument or regrettable incident with partner|relationship intimacy concerns|interpersonal ineffectiveness/conflict|boundary setting|a conflict with peers|a conflict with family|a conflict with coworker(s)|self-care/hygiene issues|sleeping issues|physical activity/exercise|substance use concerns|alcohol use concerns|cannabis use concerns|nicotine use concerns|trauma|stressor(s)/coping mechanism(s)|familial relationship distress|employment issues|financial issues|legal issues|housing issues|parenting stress|medical/health concerns|medication concerns|religious/spiritual concerns|other"][text name="variable5" default=""].

Client displays [checkbox name="variable16" 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|boundry testing| resistance to reframing|resistance to practicing coping strategies | committment/lack of committment to completing homework"].


Client [checkbox name="Response" value="was responsive and engaged|receptive to exploring the connection between thoughts, feelings, and behavior| shared homework| engaged with therapist during psychoeduction through asking questions, offering examples, and responding to questions|shifted cognitions|struggled to reframe negative thoughts during session| initiated reframing negative thoughts during session|processed emotions associated with recent life changes|was open to practicing mindfulness strategies in session|committed to practicing coping strategies independently|openly expressed thoughts and feelings related to family dynamics|was somewhat receptive to therapist's feedback|used avoiding and shifted discussion.| was resistant|pushed/respected boundaries set by therapist|made notes|committed to completing homework|made progress toward goal."]

Plan:
[checkbox name="Plan" value="Client will practice strategies introduced in session and schedule next appointment at a later date.| Client has made satisfactory progress toward achiving goals and will scheudle follow-up sessions as needed.|Client will continue with sessions"] [checkbox name="frequency" value="Session frequency: [select name="frequency" value="1x per week.|2x per month.|1x per month.|Next session on:"]