SOAP Note RF Version 3

SUBJECTIVE/CHIEF COMPLAINT
Client is a {AGE} year-old self-identified [select name="gender" value="female|male|non-binary"] who presents today on HIPAA compliant Google Meet platform for follow up on symptoms of [checkbox name="variable_1" value="depression|anxiety|panic|ADHD|PTSD/trauma|grief|adjustment disorder|relationship/marriage concerns|Bipolar disorder|insomnia|alcohol use"] Client attended from their home address and therapist from a secure office. Participants in the session included therapist and [checkbox name="participants" value="client|client's parent|client's spouse|client's family member(s)"]

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 expressed, "[text name="problem" default=""]."
The following symptoms, concerns, and updates since last session were addressed: [textarea name="concerns" default ""]

History of Presenting Illness:
[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="Insomnia1" 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 getting to sleep|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|fatigue|difficulty concentrating|irritability|difficulty falling to sleep|difficulty staying asleep|feeling tired or having little energy|muscle tension|headaches|feeling overwhelmed|poor concentration|restlessness|loss of 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|shaking|shortness of breath|chest pain/tightness|nausea/stomach cramps|numbness/tingling|fear of losing control|closed in feeling|feeling overwhelmed|heat sensations|chills|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="Insomnia1" condition="(Insomnia1).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="(Adjustment Disorder1).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|worry|difficulty concentrating|feeling overwhelmed"][textarea memo="Additional information" rows="1"][/conditional]

Focus/themes of session for today included:
[checkbox name="Symptomsmanagement" memo="Symptoms/Management" value=""][checkbox name="ADHD" memo="ADHD" value=""][checkbox name="GenderSexuality" memo="Gender/Sexuality" value=""][checkbox name="Other" memo="Other" value=""][checkbox name="Attachmentissues" memo="Attachment issues" value=""][checkbox name="Behavioralhealthissues" memo="Behavioral health issues" value=""][checkbox name="Substanceuse" memo="Substance use" value=""][checkbox name="Trauma" memo="Trauma" value=""][checkbox name="Relationships" memo="Relationships" value=""][checkbox name="Interpersonal" memo="Interpersonal" value=""][checkbox name="Adjustment" memo="Adjustment" value=""][checkbox name="Griefloss" memo="Grief/loss" value=""][checkbox name="Stressors" memo="Stressors" value=""]
[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"][/conditional]
[conditional field="ADHD" condition="(ADHD).is('')"]
[checkbox value= "ADHD symptoms/diagnosis|ADHD treatment/medications|Self-esteem|Management of executive dysfunction"][/conditional]
[conditional field="GenderSexuality" condition="(GenderSexuality).is('')"]
[checkbox value= "Gender identity|Sexual orientation|Coming out process|Reactions from family/friends/others"][/conditional]
[conditional field="Other" condition="(Other).is('')"]
[checkbox value= "Homework/assignment follow up|Goals/treatment plan review|Client history/background"][/conditional]
[conditional field="Attachmentissues" condition="(Attachmentissues).is('')"]
[checkbox value= "Adult attachment style issues|Attachment anxiety and avoidance|Adult attachment anxiety|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"][/conditional]
[conditional field="Relationships" condition="(Relationships).is('')"]
[checkbox value= "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|Previous relationship issues"][/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"][/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="Interpersonal" condition="(Interpersonal).is('')"]
[checkbox value= "Interpersonal conflict(s)|Conflict with friends|Conflict with family of origin|Conflict within nuclear family|Conflict with partner/spouse|Conflict with coworker(s)|Communication issues|Poor boundary setting/People pleasing|Difficulty saying no to others|Passive behaviors|Aggressive behaviors"][/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="Trauma" condition="(Trauma).is('')"]
[checkbox value= "Family of origin dynamics|Past trauma event|Recent trauma event|Sexual trauma event|Childhood trauma|Past childhood abuse/neglect|Past distressing memory"][/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]

Changes in medication: [text name="medication" default=""]

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

OBJECTIVE
Orientation:[checkbox name="MSE_1" value="Alert and oriented X4|Unable to assess due to cognitive impairment"] Time:[checkbox name="time" value= "On time|Late|Left early"] Appearance:[checkbox name="appearance" value="Appropriate|Clean/Neat|Casual|Desheveled"] Affect:[checkbox name="MSE2" value="Full range|Flat|Blunted|Labile|Tearful at times|Flat, tearful & congruent with depressed & anxious mood|Appropriate to mood and thoughts|Inappropriate to mood and thoughts|Restricted in range|Mood congruent"] Mood:[checkbox name="mood" value="Euthymic|Depressed|Anxious|Irritable|Angry|Sad|Elevated|Other"][text name="other2" default=""] Speech:[checkbox name="MSE4" value="Normal rate and rhythm|Pressured|Rapid|Slow|Expansive|Rambling|Monotonous|Clear|Soft"] Behavior:[checkbox name="MSE5" value="Appropriate|Inappropriate|Cooperative|Hostile|Suspicous|Guarded|Withdrawn"] Intelligence:[checkbox name= "MSE6" value= "Average|Above average|Below average"] Eye contact:[checkbox name="MSE7" value="Appropriate|Indirect|Fixed|Fleeting|Glaring|No contact"] Thought content and process:[checkbox name="MSE8" value="Logical, linear, goal directed|Circumstantial|Circumstantial but redirectable|Tangential|Flight of ideas|Perserveration|Blocking|Delusions|Preoccupations|Paranoid|Persecutory"] Insight/Judgement:[checkbox name="insight" value="Good|Fair|Limited|Poor"] Perceptions:[checkbox name= "MSE9" value= "Normal|Illusions|Depersonalization/Derealization|Hallucinations"]
A/V Hallucinations:[checkbox name="MSE10" value="No history|Denied A/V hallucinations|Endorsed auditory hallucinations|Denied auditory hallucinations| Denied visual hallucinations|Endorsed visual hallucinations"] Memory impairment: None Attention:[checkbox name= "MSE11" value="Normal|Distracted"]

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=""][checkbox name="GAD" value= "GAD7"][/conditional][conditional field="GAD" condition="(GAD).is('GAD7')"][text name="score2" default=""][checkbox name="PCL" value= "PCL5"][/conditional][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|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 disorders|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.

The client 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"]

[checkbox name="Depression2" memo="Depression" value=""][checkbox name="Anxiety2" memo="Anxiety" value=""][checkbox name="Panic2" memo="Panic" value=""][checkbox name="ADHD2" memo="ADHD" value=""][checkbox name="PTSD2" memo="PTSD" value=""][checkbox name="Insomnia2" memo="Insomnia" value=""][checkbox name="Alcohol2" memo="Alcohol Use" value=""][checkbox name="AdjustmentDisorder2" memo="Adjustment Disorder" value=""][checkbox name="Families" memo="Families" value=""][checkbox name="Interpersonal2" memo="Interpersonal" value=""][checkbox name="CBT" memo="CBT" value=""][checkbox name="General2" memo="General" value=""][checkbox name="EMDR" memo="EMDR" value=""]
[conditional field="Depression2" condition="(Depression2).is('')"]Interventions provided include [checkbox value="identified patterns of depression|encouraged engaging in and monitoring self-care (hygiene/grooming)|explored potential reasons for sadness|assessed history of depressed mood|identified symptoms of depression|identified support system|normalized feelings of sadness|encouraged journaling feelings as coping skill|identified coping skills to use when feeling depressed|reinforced/encouraged physical activity"][textarea memo="Additional information" rows="1"][/conditional]
[conditional field="Anxiety2" condition="(Anxiety2).is('')"]Interventions provided include [checkbox 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"][textarea memo="Additional information" rows="1"][/conditional]
[conditional field="Panic2" condition="(Panic2).is('')"]
Interventions provided include [checkbox value="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 interceptive exposure activities|provided psychoeducation on 'window of tolerance'|explored distress tolerance skills|encouraged medication evaluation|practiced grounding techniques"][textarea memo="Additional information" rows="1"][/conditional]
[conditional field="ADHD2" condition="(ADHD2).is('')"]
Interventions provided include [checkbox value="encouraged use of positive self-talk exercises|explored and identified time management skills|explored organizational skills|explored prioritization skills|encouraged outside reading on ADHD/neurodivergence|provided education about ADHD/neurodivergence|identified strengths/positive qualities|explored social constructs|explored and identified trauma due to undiagnosed neurodivergence in childhood"][textarea memo="Additional information" rows="1"][/conditional]
[conditional field="PTSD2" condition="(PTSD2).is('')"]
Interventions provided include [checkbox value="explored trauma history and impacts on client's life|explored and identifed 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"][textarea memo="Additional information" rows="1"][/conditional]
[conditional field="Insomnia2" condition="(Insomnia2).is('')"]
Interventions provided include[checkbox 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"][textarea memo="Additional information" rows="1"][/conditional]
[conditional field="Alcohol2" condition="(Alcohol2).is('')"]Interventions provided include [checkbox value="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"][textarea memo="Additional information" rows="1"][/conditional]
[conditional field="AdjustmentDisorder2" condition="(AdjustmentDisorder2).is('')"] Interventions provided include [checkbox value="identified support system|normalized feelings of sadness/anxiety in reaction to stressor|encouraged use of coping skills|explored and practiced relaxation strategies|identified and processed thoughts and feelings related to stressor|identified alternative behaviors/coping skills that have helped in the past"][textarea memo="Additional information" rows="1"][/conditional]
[conditional field="Interpersonal2" condition="(Interpersonal2).is('')"] 
Interventions provided include [checkbox value="explored how fear of disappointing others affects functioning|assisted client with identifying positive aspects of self|explored and assigned positive affirmations to practice|encouraged and reinforced use of positive self-talk|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|reviewed healthy methods of de-escalation"][textarea memo="Additional information" rows="1"][/conditional]
[conditional field="Families" condition="(Families).is('')"] 
Interventions provided include [checkbox 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"][textarea memo="Additional information" rows="1"][/conditional]
[conditional field="CBT" condition="(CBT).is('')"] 
Interventions provided include [checkbox 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"][textarea memo="Additional information" rows="1"][/conditional]
[conditional field="General2" condition="(General2).is('')"] 
Interventions provided include [checkbox 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|assessed client's symptoms and history|reviewed family of origin hx/dynamics|role playing|modeled behaviors|collaborated with client to problem solve|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 discussing progress towards goals|assisted client with identifying and setting goals|administered clinical assessments and discussed meaning/results|explored and discussed termination|worked with client on planning 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| "][textarea memo="Additional information" rows="1"][/conditional]
[conditional field= "EMDR" condition= "(EMDR). is ('')"] Interventions provided include [checkbox value= "Phase 1: Trauma history and treatment planning,| Phase 2: Preparation/Resourcing,| 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]

The client’s observable reaction to these interventions were: [checkbox name="reactions" value="positive|engaged|motivated| open|resistant|reluctant|negative|hesitant"]

Treatment progress:
Treatment goals addressed/worked on this session include [textarea name="variable_1" default="" rows="1"]
Client progress in achieving treatment goals is best assessed as [checkbox name="progress1" value="responding well to interventions|making some progress|slow/slight progress|fluctuating/intermittent progress|maintaining past gains|maintaining current goal focus|an increase in symptoms|a decrease in symptoms|a significant escalation in symptoms|minimal|improving|stable"] as evidenced by client self-report, observed behavior, and level of engagement.The client's ability to identify and utilize [textarea="" rows="1"] techniques indicates progress in therapy and an increasing mastery of self-regulation tools. The improvement in the client's mood suggests a positive response to therapeutic intervention.The client displayed insight into the connection between their diagnoses and the challenges they face daily.

PLAN:

Changes in diagnosis or treatment plan: [text box="changes" value="None"]

Therapist will utilize the following therapeutic modality at next session: [checkbox name="ebt" value= "CBT|EMDR|CPT|PE|Mindfulness-based|Behavioral activation|TF-CBT|Solution-Focused Therapy|DBT skills"]
Focus of next session will be on [textarea="" rows="1"]
Therapist will follow up on [checkbox name="followup" value="activity scheduling|reframing/identifying cognitive distortions|mindfulness exercises|self care|spending time with others|prioritization/time management|setting/maintaining boundaries|utilization of communication tools|utilization of coping strategies|journaling|modifying eating/exercise habits|other"] and will review [checkbox name="checkon" value="homework/outside assignment|recent stressors/emotional experiences|symptom intensity/frequency|goal achievement/outcomes"] with client at next visit.

Homework: Ct agreed to [text name="homework" default=""].

Frequency of sessions:
[checkbox name="plan1" value="Weekly individual therapy.|Biweekly individual therapy.|RTC in 1-2 weeks.|RTC in 2 weeks to assess relationship functioning and review progress.|RTC in 1 month to assess functioning/progress.|Client will contact Provider to schedule next session.|Provider will contact Client to schedule next session."]
The service provided is medically necessary and appropriate for the treatment of the diagnosed condition to: [select name="neccessity" value= "Address symptoms/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."]