Note Template

60 Minute Session Medically Necessary due to: (complex trauma history/ongoing treatment of serious mental illness)

Location (If Telehealth):

Note:

Assessment:

Observations:

Cognitive Functioning: Oriented / Alert, Disorganized, Tangential, Preoccupied, Circumstantial

Affect: Appropriate, Inappropriate, Labile, Constricted, Blunted, Flat

Mood: Euthymic, Depressed, Dysphoric, Anxious, Angry, Euphoric

Interpersonal: Interactive, Intermittently Interactive, Guarded, Withdrawn, Hostile

Functional Status: Intact, Impaired, Variably Impaired

Risk Factors:

None
Suicidal Ideation
Homicidal Ideation
Drug Relapse Potential

Current Functioning, Symptoms, or Impairments:

Content or Topics Discussed:

Interventions:

Acceptance and Commitment Therapy (ACT)
Behavioral Activation
Cognitive Behavioral Therapy (CBT)
Cognitive Challenging
Cognitive Refocusing
Cognitive Reframing
Communication Skills
Dialectical Behavioral Therapy (DBT)
Evaluation
Existential Therapy
Exploration of Coping Patterns
Exploration of Emotions
Exploration of Relationship Patterns
Exposure Therapy
Goal Setting
Guided Imagery
Insight
Interactive Feedback
Interpersonal Resolutions
Mindfulness-Based Cognitive Therapy (MBCT)
Mindfulness Training
Motivational Interviewing
Preventative Services
Problem Solving

Treatment Plan Progress:

Objective 1:

Additional Notes Regarding Goals and Objectives:

Plan:

Recommendation:

Continue Current Therapeutic Focus
Change Treatment Focus
Terminate Treatment