(paraphrase only and exclude direct quotes)
(IF right brain mode: avoid full sentences except for direct quotes, minimize word count without sacrificing clinically meaningful detail)
(for the entire document: please delete any empty note elements such as elements that are labeled in the note as "not explicitly mentioned" such as omit the medication section if no medications were mentioned)
(Please write in super detailed mode)
(If content for a placeholder item is empty, omit the item in the note; put placeholder content in one paragraph with no line breaks, placeholder content can be separated by comma or colons)
(section headings with to be printed in bold, please print labels for lists in bold e.g. item label: text describing item)
(please separate sections with long rows of dashes including between the following sections: GENERAL SESSION INFORMATION, PRESENTING CONCERNS, MEDICATIONS, FUNCTIONING AND UPDATES SINCE LAST SESSION, MENTAL STATUS EXAMINATION, RISK ASSESSMENT, RISK MANAGEMENT, SESSION SUMMARY, INTERVENTIONS, NEXT STEPS)
(A CCS client is a client who has a CCS Recovery plan in the Contextual notes)
GENERAL SESSION INFORMATION
- ["Type of session": individual, parent session, family session]
- ["Attendees": list all participants such as client, mother, father, CCS Facilitator, if school staff present list name and job title as is available]
Place of service: [office, virtual, school, other (describe)]
Type of service(s) provided: (only for CCS clients) [list all applicable services: Individual therapy, family psychoeducation, service planning](if parents are present that is family psychoeducation, regardless of if patient was present or not; session time with just patient is considered individual therapy; if CCS Service Facilitator is present then the service is always considered service planning)
[if possible list start and end time as well as total minutes each for each type of service]
Client needs addressed in session: (only for CCS clients)[use CCS consumer needs list of the CCS recovery plan from the text addition and list in progress note any of them that were addressed in session] (CCS Needs, CCS Goals, CCS Objectives are only reported in the session note verbatim)
CCS goals and CCS objectives targeted in session: (only for CCS clients)[use CCS Goals list of the CCS recovery plan from the text addition and list in progress note any of them that were addressed in session] (CCS Needs, CCS Goals, CCS Objectives are only reported in the session note verbatim)
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PRESENTING CONCERNS:
- [brief summary of Concerns and symptoms presented by the patient](a few brief bullet points)
MEDICATIONS: [only include this if there is explicit reference to medications]
[- Any mention about medications & efficacy and side effects]
MEDICAL UPDATES: [only include if explicit references to medical problems or medical intervention updates were made]
[- Medical problems updates;]
[- Medical intervention updates:]
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FUNCTIONING AND UPDATES SINCE LAST SESSION:
(use bullet points, bullet point for each place holder; after the placeholder label list the description without line break like the style of the clinical formulation section, please print each place holder label in bold font and italicize, please only one line break between placeholders and please do not list sub-items in bullet style and instead in a list without line breaks)
(use similar style to clinical formulation section)
(make sure to be specific regarding symptom severity, frequency etc.)
- _Progress made since last session:_
- _Setbacks encountered during treatment:_
- Prior session homework: [include here anything relevant to prior homework]
- _Ongoing challenges or issues:_
- _General updates:_ [any relevant updates not already included in the progress,setbacks and ongoing challenges sections]
- Parental reports about insight and judgement: [if this is empty, omit this]
- Between session therapy interfering behaviors: [Behaviors exhibited between sessions that interfere with getting optimal benefit from therapy – such as incomplete homework, resisting following recommendations or trying out interventions between sessions, inconsistent implementation of skills or therapy engagement, if none were identified write "none identified"]
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MENTAL STATUS EXAMINATION: (only include if the session included patient, exclude if it was a session without patient such as a parent session)(bold) (italicize each element name for this section)
- _[Appearance, Speech, Affect, Thoughts, Perceptions, Cognition, if applicable/mentioned]_
- _[Behavior observations]_
- [_Affect and Mood assessment_]
- _[Insight]_
- _[Judgment]_
[Behavior observations: include here observations about parent behavior if this is a parent session]
In-session therapy interfering behaviors: [Behaviors exhibited during session that interfere with getting optimal benefit from therapy – such as resisting following recommendations, directions, homework recommendations, skills practice in session, avoidance of therapeutic tasks during sessions, limited effort or engagement during sessions, emotional reactivity and impulsivity or poor focus in session, in-session incomplete reporting of important events and updates that occurred in-between sessions; if no behavior was identified write "no significant in-session behavior observed]
Past Medical & Psychiatric History: [only include if there are any explicit mentions](bold)
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RISK ASSESSMENT
- [Detailed description of both ideation and behaviors relating to suicide, self-harm, aggression, homicidal urges, addictive behaviors; if no safety concerns described note – “no safety concerns reported or observed"]
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CLINICAL FORMULATION:
(use bullet points, bullet point for each factor; list the factor description right after the placeholder label without line break, please print factor names in bold and italicize)
- _Prompting events and Precipitating Factors:_ (Recent events or stressors triggering current condition)
- _Enduring and Chronic risk factors including Predisposing Factors:_ (Patient's historical factors contributing to current condition)
- _Dynamic risk factors and Short-term risk factors:_ (including stressors, current psychiatric symptoms, peer & relationship functioning)
- _Perpetuating Factors:_ (Factors that maintain or exacerbate the condition)
- _Protecting Factors:_ (Patient's strengths and resources including skills, and social support; if existing: positive relationship with therapist, future orientation, hope, connectedness, reasons for living)
RISK MANAGEMENT (bold)[If applicable, if no risk reported or observed, omit]
- [describe commitment to staying safe and use safety plan]
- [If applicable: Safety plan: including plan to use skills to mange unsafe urges, restriction of means of harm, external resources for support (only mention them if they were explicitly identified): including therapist, parents, friends, other professionals, teachers, suicide hotline, emergency room, 911)
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INTERVENTIONS:
(use bullet points, bullet point for each place holder; after the placeholder label list the description without line break like the style of the clinical formulation section, please print each place holder label in bold font and italicize it, please only one line break between placeholders and please do not list sub-items in bullet style and instead in a list without line breaks)
(use similar style to clinical formulation section)
- _New strategies or techniques taught:_
- _Psychoeducation:_ (include here education that does not involve skills or strategy teaching)
- _Validation:_
- _Behavior chain analysis:_
- _Behavior analysis_:
- Solution Analysis:
- Missing Links:
- Assessment: (any other assessment besides behavior chains or behavior analysis)
- Role play or practical exercises conducted: (this includes any in-session skills practice)
- Problem Solving:
- Behavior Activation: (including any activity scheduling including routine activities, pleasant activities, value-based activities] (Only include if direct evidence or mention, if it seemed it did not occur, leave item out; do not include in-session activities unless they are explicitly labeled as behavior activation)
- Formal exposure:(formal planned in-vivo exposure or imaginal exposure or exposure planning such as setting up exposure hierarchy)(Only include if direct evidence or mention, if it seemed it did not occur, leave item out, provide details regarding anxiety ratings and any behavioral observations or otherwise relevant details to exposure)
- Informal exposure: (not planned exposure, any confronting of a uncomfortable emotion can be anxiety, shame, anger)
- Frustration Tolerance and impulsivity management practice (include here also delayed gratification)
- Emotional experiencing: (when patient experienced emotions in the moment e.g. grief in a skillful way)
- IFS - Parts work:(describe parts work if parts and the Self are mentioned and name the parts involved in the parts work and brief description of process and outcome of parts work)
- Processing and exploring:
- Treatment Planning:
- Continued treatment strategies: (previously taught strategies that were reviewed, DO NOT include review or prior session homework here, this is only for strategy/skill review besides prior session homework review)
- Troubleshooting implementation of strategies:
- _Specific strategies and techniques discussed:_ (if not already mentioned as another intervention, do not mention homework here, do not list here a skill taught - that belongs to the "New Strategies or techniques" section)
- (List any other interventions such as, processing and exploring, psychoeducation, problem solving, treatment planning, assessment, behavior chain analysis) (Only include if direct evidence or mention, if it seemed it did not occur, leave item out)
Relevance to CCS goals and objectives[only include this if this is a client with a CCS Recovery Plan, otherwise DO NOT include this item in the note; briefly escribe how each intervention related to a specific CCS goal or objective; please only quote verbatim CCS goals or objectives, do not make up CCS Goals or Objectives]
RECOMMENDATIONS MADE: (omit if none were made, homework is not a recommendation)
RESPONSE TO INTERVENTIONS
[Description of how client responded to interventions including was open to education about them, was resistant to them including resisting trying them in or out of session and or how open client of family members were to implementation of strategies or response to therapists attempts to engage or validation or encouragement related interventions or how open to assessment by therapist client or family was]
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SESSION SUMMARY:
- [Focus of the session]
SESSION CONTENT:
- [Detailed description of the session] (only include information here that is not mentioned in interventions yet, do not include simple updates here as those belong in the update section)
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TREATMENT PLAN:
- [Adjustments to treatment schedule] (only include if direct mention of it)
- [Goals for Treatment as bullet point list]
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NEXT STEPS:
(use bullet points, bullet point for each place holder; after the placeholder label list the description without line break like the style of the clinical formulation section, please print each place holder label in bold font, please only one line break between placeholders and please do not list sub-items in bullet style and instead in paragraph style using commas and semicolons as necessary)
- [Next session scheduled] (only include if direct mention of it)
- [Patient's agreement or decisions regarding treatment] (only include if direct mention of it)
- [_Client homework_: Assigned homework or tasks for the patient and or parents, please be very specific including what specific skill or strategy, frequency and duration and how the skill or strategy is to be practiced]
- [Continued skill practice and self-care] (only include if direct mention of it)
- [_Follow up tasks for psychologist:_ Documents to share, school or other treatment team members to contact, any other tasks psychologist mentioned for self to complete; please be very specific] (only include if direct mention of it)
- _Plan for next session_ (if there is a plan referenced, include item here including follow up for next session)
- Considerations for future sessions