LCSW note

Session Location:Virtual session using HIPAA compliant telehealth app [textarea name= default="Zoom/Spruce an interactive telecommunications system"]  
Diagnoses: [textarea name= default="F43.1. Post Traumatic Stress Disorder Chronic F90.9 Attention Deficit Disorder Combined Presentation F34.1 Persistent Depressive Disorder  Eating Disorder Unspecified F450.9 "]
Risks [textarea name= default="Denied SI, HI, NSSIB, AVH"]
Status: [textarea name= default="stable, improved, decline, worsened, no change"]
Health Status/ Medication Compliance[textarea name= default="Health is stable, taking medications as prescribed.No changes to medication, currently prescribed"]
Response to Treatment: [textarea name= default="engaged, precontemplative, contemplative, externally motivated"]
Notable changes or developments since the last session: [textarea name=default="sample text"]
Appearance: [textarea name= default="Appropriate"]
Judgment: [textarea name= default="WNL, automatic, impaired"]
Insight:[textarea name=default="denial, WNL, extenal locus of control, intellectual, full emotional insight"]
Orientation[textarea name= default="Person, Place,Time, Situation"]
Reality Testing[textarea name= default="WNL,impaired"]
Speech: [textarea name= default="WNL, slow, stutters, rapid, loud, hesitant, responsive, "]
Memory Impairment: [textarea name= default="None/ Intact, working, recent remote/ Fragmented, amnesia "]
Thought Process: [textarea name= default="Cohesive /Goal Oriented, Delusions, Trend of thought, poverty of thought, egomania, monomania"]
Mood: [textarea name= default="Euthymic,Dysthymic, Anxious"]
Eye contact [textarea name= default="WNL, fleeting, fixed, glaring"]
Motor Activity [textarea name= default="WNL, restless, slowed, lethargic"]
Affect [textarea name= default="congruent full, /incongruent, constricted, blunted, expansive"]
Session Details:[textarea name= default="They had privacy, and the connection was good."]
Treatment Interventions:[textarea name= default="Validation, CBT, Supportive Reflections, Psychoeducation, Mindfulness, Client-Centered, Elucidation, exploration of patterns, Cognitive Reframe, Trauma-informed, modeling healthy communication, explore schemas, Problem Solving"]
Goal(s)/Objective(s) and Progress for each goal/objective[textarea name=default="1. Learn and implement approaches for addressing shame and self-disparagement. / in progress "][textarea name= default=" . stabilize mood. Progress: in progress
2 Discuss and resolve troubling personal and interpersonal issues Progress: some resistance.
3. Identify and replace thoughts and behaviors that trigger manic or depressive symptoms: in progress Learn and implement guided self-dialogue to manage thoughts, feelings, and urges brought on by encounters with trauma-related situations. / in progress. Identify, challenge, and change self-talk that contributes to maladaptive feelings and actions: In progress."][textarea name= default="Increase insight into low self-esteem's historical and current sources. Progress: in progress"][textarea name= default=" Form realistic, appropriate, and attainable goals for self in all areas of life. Progress: good progress"][textarea name= default="3. Identify and replace thoughts and beliefs that support depression. Progress: Good progress Identity, challenge, and change self-talk that contributes to maladaptive feelings and actions Progress: in progress"][textarea name= default=" Strengthen and practice calming strategies when feeling overwhelmed / in progress 2. Implement a regular regimen of movement as a stress release technique. / In progress "][textarea name= default="Minimize ADD behavioral interference in daily life and Achieve a satisfactory level of balance, structure, and intimacy in personal life"]
Homework[textarea name= default="None given, encourage them to reflect on today's discussion, practice skills modeled in todays session, work on shared google document to explore"]
Referals[textarea name= default="None given, psychiatrist information, social services, support group, website"]
Plan [textarea name= default="Continue to meet weekly "]