General Introductions

Use this time to introduce yourself to the client/parents/guardians and explain what they can expect during this important phase of treatment.

It is at this time that you begin the therapeutic alliance and initiate the intake/assessment process.

Explain to the client/guardian the purpose of the intake process i.e. gathering important information so as to understand presenting concerns and emphasize that this is not what therapy is normally like but rather this is about gathering the facts, background and history of the presenting issues.

If doing an assessment on a child/minor, it is important that the child participate in the assessment process.

Age

Referral Source

Presenting Problem (What has been going on that the client is seeking treatment).

Client reports that she has been experiencing a difficult time adjusting to recent changes in her life. Per client "I am really struggling with understanding why my husband left me", noting a loss of passion and purpose in her life. Client was the only person present for this virtual assessment process. Client was open, cooperative and collaborative in the assessment process.

**Suggestion**The use of client/parent quotations is person-centered and considered a good practice to ensure that we get a good look at the client/parent's perception of what is going on.

op

Development and Duration of Issues

In this section, you begin to document the history of the problem, how frequently the problem is occurring, document specific symptoms and other pertinent issues that have contributed to the development of the presenting issues.

Jessica has been experiencing problems with focus and attention for the past two years, with recent increases due to increased stress in the home. Mother reports that Jessica's father recently left the home and as a result of this, Jessica has been experiencing increased difficulties i.e. lack of concentration, difficulty following directions, easily distracted, difficulty sitting still or controlling impulsive behaviors. Symptoms have been present in the home, school and community settings with mild to moderate severity.

Family Functioning- (family composition, who lives at home, relationship with family)-

This is where you document with whom a client is living, the conditions of the home environment (is it chaotic? supportive?), interactions and relationships with family members.

Jessica lives at home with her mother, older brother (Eddy, age 14),and two maternal aunts. Client and mother describe their home life as chaotic yet supportive and loving. Client does not have a strong relationship with her father who has recently left the home, having separated from the mother and left the state.

**Suggestions** For children/minors ask about extended family relationships and support network, stressors related to child custody. For adults, ask about their relationship with parents, siblings, significant others or other extended family members.

Social Functioning (support system, after-school activities Speak to any social interactions that are known, do they have many friends, a good support system, do they shy away from relationships, describe any behavioral concerns at home, school or community.

Jessica has a good social support network, is involved in team sports and is described/observed as a social butterfly.

**Suggestions** Spiritual or religious affiliations, interests, hobbies, sports, what they do for fun and list client strengths.

Educational/Professional History- Current grade level and school name, IEP/504 plans? If an adult- up to what education level did they obtain (HS diploma, Bachelor's degree), What do they do for a living? Have they repeated grade levels? Are there behavioral issues at school?

Jessica is currently enrolled in the third grade at Siler City Elementary and is receiving services through an Individualized Educational Plan (IEP). Client is struggling academically due to presenting symptoms.

Treatment History- Here is where you document any history of psychiatric treatment including hospitalizations, previous counseling experiences, outcomes of treatment, substance abuse, etc.

Jessica is currently taking Focaline 20 mlg- prescribed by her pediatrician. Client has not had any counseling experience in the past and has not be hospitalized due to psychiatric issues.

**Suggestion** Ask about self-harming behaviors and SI/Hi and document this here.

Family Psychiatric History- This is where you document any family history of psychiatric disorders including parents, siblings, grandparents. If none, simply state: No reported family history of psychiatric issues. Substance abuse should also be documented here (family and client history).

With Notable History

Jessica 's mother has been previously diagnosed with ADHD and father has unknown history of psychiatric issues.

Without Notable History

Client/parent denies a history of family psychiatric issues.

Medical History- Any medical issues (include client)are to be reported here including history of developmental issues (developmental milestones met on time?). Include history of accidents, previous illness, hospitalization for medical issues), allergies. Include the name and contact information for Primary Care Physician, medication list.

No Medical Issues:

Client denies any significant medical issues or history that would impact diagnosis or treatment at this time.

Medical Issues

Client reports having a history of asthma, currently under physician's care. Client also reports that she is taking medication to treat high blood pressure (name and dosage unreported by client).

No Developmental Issues

Client has met all developmental milestones appropriately with no reported medical history that would impact or affect diagnosis and treatment at this time.

Developmental Issues

Client/parent report a significant speech delay which impeded functioning and academic performance for the first 3 years of elementary school. Issues have since resolved.

**Suggestions** include pre-natal information, maternal use of alcohol or drugs, premature? What are client's sleeping and eating habits?

Trauma History- Report any history of trauma reported or noted by client/family. If there is no known history of trauma including: child abuse, neglect, sexual trauma, significant losses, natural disasters, exposure to domestic violence (current or past), incarcerations, report as such:

No Trauma

Client denies history of traumatic events including but not limited to: childhood abuse, neglect or sexual trauma. Client did not experience interpersonal violence, exposure to violent acts or natural disasters.

Trauma History

Client reports sexual abuse by a family member at age 8 (one incident, reported to police). Client identifies this as a major concern still as she has had a hard time relating to others. Client further notes that her childhood was relatively chaotic, both parents arguing in her presence for extended periods of time. Client denies CPS involvement or physical violence.

Mental Status Examination- Mark all pertinent areas in each section of this box.

Suggestions: Make sure that you identify any suicidal ideations.

Integrated Summary- This is the synopsis of the assessment or a snapshot of the client and should be able to be read as a "standalone" document highlighting the major information which should include the following:

• Demographic information, presenting concerns, development of symptoms, and substantiate your diagnosis in your integrated summary. You can copy and past from the above boxes to streamline the process.

• Document client presentation, interactions with clinician, other people involved and who was present during the assessment.

Client is an 8 year old Hispanic male whose parents are requesting an evaluation to learn skills to help client with his symptoms of ADHD. Per client's parents "Fernando is having a very hard time concentrating, following directions and is impulsive". Client's parents’ note that he has been diagnosed with ADHD by his primary care physician and has re-started medications recently. Father also notes that he believes that he (father) could benefit from parenting techniques to help his son.

Client was diagnosed last year with ADHD and has been recently started on medications to treat this (name of medication is unknown to parents at this time). Client has had on-going struggles with his academics and behavior for several years. Symptoms include: inability to concentrate, difficulty following directions, lack of control over impulses, talking incessantly, high level of motor activity and is easily distracted. Symptoms are present in the home, community and academic setting. Client lives in a single-family private residence with his mother who is from Guatemala, his father who is from Honduras and is 4 year old sister. Client describes his home life as "good" and feels loved and supported by his parents.

Client is currently enrolled in the 3rd grade at Beaver Dam Elementary and does not currently have an IEP in place. Parents were encouraged to explore this option due to client's previous diagnosis of ADHD. Client is not doing well academically but has only recently started medications. Client gets along well with others in his classroom, despite often getting in trouble for inability to control his talking or being able to sit still in the classroom. Client believes that he has good peer interactions.

When client was born, he had a small stroke that impacted the right side of his body. Client favors his left side. Client received occupational therapy until he was a year old. Long-term impacts of this stroke are unknown at this time. No other medical issues were reported and client denies history of traumatic events.

Client meets diagnostic criteria for ____ due to exhibiting the following symptoms: (list the symptoms, duration, frequency, severity).

Diagnosis- In this box, we start by giving the DSM 5 diagnosis (including any rule outs or V/Z codes) using ICD 10 codes.

314.01 (F90.2)- Attention Deficit Hyperactivity Disorder-Combined Presentation

Treatment Recommendations/Plan: In this section, you type up the general recommendations regarding treatment including methods, strategies or interventions that are pertinent to that specific client.   

Weekly to biweekly (dependent upon availability) individual OPT that focuses on developing improved functioning and skill-building so as to decrease presenting symptoms. Modalities may include but not be limited to: DBT-informed interventions, CBT, Motivational Interviewing, Solution-focused interventions, Expressive therapies and other evidence-based interventions. Client was oriented regarding these recommendations and is in agreement. Client was also educated regarding the process for 24 hour crisis coverage, cancellation policy, client rights and responsibilities, informed consent and limits of confidentiality. A follow up appt. was scheduled.

**Suggestions** Include what treatment modalities, include 24 hour crisis coverage policy, general contract information and frequency of recommended treatment, including referrals.

The treatment plan is to be completed as part of the intake process. We have included the Tx Plan Cheat Sheet for you to use when creating your treatment plan. The client (when intake paperwork has been done online) has already signed an agreement to the treatment plan. We suggest talking with the client, during the assessment process, about general goals and then creating the treatment plan co-jointly (if laptop and wifi access is available) with client or creating it and reviewing it with the client, in more depth, at the next session. In the Google Doc below, the very first section (Recommendations) can also be copied into the assessment and modified to meet individual needs!

Progress Notes are to be completed within 24-48 hours of the date of service. This is an insurance requirement and is of utmost importance to adhere to. If a progress note is not completed within that time frame, billing is delayed and we run the risk of a "pay-back" if audited by the insurance company.

In the event of a family emergency or extenuating circumstances, please reach out to Sam to discus this.

The progress note in Theranest is divided into three main writing boxes

Service Date & Time- Click on the date of service and then move to Appointment, when you click on the arrow to the side, a drop-down menu will populate the appointment date and time therefore linking it to the appointment.

Move down to Mental Status and click in the white text box to open up a bunch of pre-populated options. You can also type in the box the words that you would like to add.

• Session Focus: This section documents what was focused on during the session

• Therapeutic Intervention: This section documents what interventions were offered.

• Planned Intervention: This section is to document client response and progress being made.

  • Progress Note with NoteDesigner Video