Telehealth

Clinician met with client for tele health session via video and audio. Client verified DOB

and home address. Client reported that they were at home.

Clinician met with client via telehealth audio and video at client's home, and verified two

forms of identification (DOB

and Home Address) and current location (Home Address) prior to video telehealth appointment.

Client reported that they were at __________ in the community. Client provided address

of their location.

Clinician engaged client with an audio and video tele-health session. Client identified

his/her identity and location with a photo ID and stated that they were at their home address,

which is the same one that is on file.

Clinician engaged client with an audio and video tele-health session. Client identified

his/her identity with a photo ID and stated that they were located at __________________.
 In office

Clinician met client at the office face-to-face (or in-person).

General Note template:

Clinician met client at the office face-to-face. Clinician built rapport with client, checked

in with client's current level of functioning, and reviewed treatment plan goals together. Client

further processed current feelings and stressors. ________ Clinician used supportive reflection,

open-ended questions and Socratic questioning, as well as active listening skills to validate his

emotions. Clinician utilized psychoeducation to review basic ________coping skills with client.

First session/ITP Session:

Clinician met with client face-to-face in the office. Clinician built rapport with client,

checked in with client's current level of functioning, and established treatment plan goals

together. Client was able to contribute to treatment plan goals. Clinician utilized

psychoeducation to teach client basic coping skills and relaxation techniques including deep

breathing, radical acceptance, and grounding techniques. Client reports being willing to give

these techniques a try this week.

 ITP update:

Clinician met client at the office face-to-face. Clinician built rapport with client and

checked in with client's current level of functioning. Client and clinician reviewed and re-

established treatment plan goals together. Client and clinician further processed the treatment

plan and how client has progressed in the goals established 90 days ago. Client contributed to the

treatment plan goals and wanted to maintain the goals for the most part. Clinician and client

edited a couple of goals to further and specify his treatment goals.

First session for couples:

Clinician met with clients face-to-face in the office. Clinician built rapport with clients,

checked in with clients' current level of functioning, and established treatment plan goals

together. Clients were able to contribute to treatment plan goals. Clinician provided information

about the Gottman's couples counseling. Clinician utilized psychoeducation to teach clients basic

coping skills for communication, fair fighting, and love language. Client reports being willing to

give these techniques a try this week.

Contact note:

Clinician attempted to reach client to see if client is still interested in services. Client did

not respond to any communications.

Clinician contacted client to see if she is still interested in services.

 Contact Note to Probation Officer:

Clinician reported client's attendance of his session today to client's Probation Officer.

Contact note after sending treatment plan to client:

Clinician emailed client the ITP and released the ITP on therapy Notes Portal so client

has access to sign and review the ITP.

Cancelation Contact note:

Client scheduled for an in-person visit. After waiting 5 minutes, clinician attempted to

call to see if client was still doing in person session. Then clinician reached out to client. Client

did not respond to any communication. Clinician canceled the session after 15 minutes of no

response from the client.

Client was scheduled for a video visit. After waiting 5 minutes, clinician attempted to call

to see if client was still doing joining the session. Then clinician reached out to client. Client did
not respond to any communication. Clinician canceled the session after 15 minutes of no

response from the client.

Right before scheduled time of appointment clinician called and emailed client. Client

did not respond. Clinician called client again at the time of scheduled appointment. Client did not

pick up the phone and it did not have an option to leave a voicemail.

Transition/Discharge Plan:

When the client and clinician have determined that the client has completed all of ITP

goals and client is able to adequately communicate emotional assertively and able to utilize

coping skills constructively; client will be eligible for discharge.

When the client and clinician have determined that the client has completed all of

his ITP goals and is able to adequately communicate his feelings respectfully and able to utilize

his anger constructively client will be eligible for discharge.

 The client will be eligible for discharge and eligible from graduating from counseling,

once he/she has met the following goals.….

Discharge:

Client will benefit from ongoing outpatient counseling. Writer did inform client that,

should symptoms persist or worsen, they are welcome to re engage in services at this or another

agency. Writer provided resources for continuity of care. Please reach out to a crisis office. Text

the keyword “4hope” to 741 741 or call (614) 722-1800 or go to closest ER.

Should symptoms persist or worsen, they are welcome to re engage in services at this or

another agency. Writer provided resources for continuity of care. In an emergency, please reach

out to a crisis office. Text the keyword “4hope” to 741 741or call (614) 722-1800 or go to closest

ER.

Goal: Develop and implement effective coping skills that allow for carrying out normal

responsibilities and participating in relationships and social activities

 Goal: Learn and implement anger management techniques

Client did not display progress as evidenced by reported engagement in anti-social

behaviors that led to her arrest. At the time of discharge, the client had been released from a

juvenile facility and was residing in a residential group home versus foster care placement due to

behaviors.

Client was making progress but after sending out letter of attendance to Probation officer,

client no longer attended sessions.

Client has had a lot of ups and downs and has been in counseling for several years. Client

has started working a more stable job and has not called back to reschedule.

Client started taking his medications and practicing the coping skills and he has benefited

greatly from the services. Client feels that he no longer needs services.

Uncertain. Client attended 4 sessions after the assessment and did not come back.

Client attended assessment only.

Client did not complete any services. Client did not complete paperwork or schedule an

assessment.

Client did not complete intake paperwork or attend an intake session

Client would benefit from continued counseling but has chosen to discontinue services at

this time.
 Client has made a lot of progress and having a break from services may be beneficial or

satisfactory at this time. Client is always welcome to come back to counseling when/if needed.

Client denies. Client feels he has accomplished his goals at this time.

Client discontinued services without notice to the agency.

Client discontinued contact without notice to the agency.

Unknown. Client may still benefit from counseling.

Uncertain. Client did not schedule and complete an assessment.

Client communicated with client, letting clinician know that he wants to withdraw from

services as he has to work "out of town" so he is not able to commit to services at this agency.

Client reports that he will find anger management services later with a more geographically local

agency.

Assessment:

Client met with client face-to-face at the office.

Client is a ….

Client meets the criteria for…

 Clinician recommends…

The clinician recommends CPST services to provide support and resources to address

financial barriers.

The clinician recommends at least 12 weekly individual counseling sessions to address

symptoms. The clinician will

assess to determine if additional sessions will be needed after the initial 12 sessions due to lack

of progress while in

treatment. The clinician will monitor the client’s SUD symptoms to determine if the client would

be appropriate for a

higher level of care.

The clinician explained agency grievance and confidentiality policy. Client verbalized

understanding.

EMDR Templates:

Client and clinician completed Phase 2 of EMDR.

 Clinician taught client tools to improve client’s internal and external resources, as well as

discussed current management of stressors and triggers. Client created/strengthened their coping

skills with bilateral dual attention stimulus (DAS). Clinician taught client relaxation techniques

including deep breathing, light stream guided visualization, happy place meditation, and

container script. Client was very engaged in learning and responded well to the resource skills

for EMDR.

Clinician and client completed EMDR Therapy Phases 3-7 used to begin reprocessing

first/worst/most recent floatback targets (regarding father's attitude and loneliness this past

winter) for negative cognition/blocking beliefs related to isolated and judged (I am not safe/not

confident/ trapped and lonely). Client's beginning SUD = 9, VOC =7. Client was able to tolerate

and reduce emotional distress during reprocessing with fast dual attention stimulus. Ending

VOC=7, SUD = 1. Positive belief (I am good enough, I am deserving of love, I am successful

and I am loved) installed with an adaptive and clear body scan.

Phase 7 was used to debrief reprocessing, discuss any identified concerns and insights,

and plan for next session.

Clinician and client completed EMDR Therapy Phases 3-7 used to begin reprocessing

first/worst/most recent floatback targets (related to his health scares) for negative

cognition/blocking belief related to responsibility, power, and control. Client's beginning SUD =

5, VOC =2 . Client was able to tolerate and reduce emotional distress during reprocessing with
fast dual attention stimulus. Ending VOC=7, SUD = 0. Positive belief (I am healthy and

compliant with health) installed with adaptive and clear body scan.

Phase 7 was used to debrief reprocessing, discuss any identified concerns and insights, and plan

for next session.

Intervention & Response Language

Phase 1 EMDR Therapy Phase 1

Clinician and client identified potential targets for reprocessing with fast dual attention

stimulus, including first, worst, and most recent memories obtained via floatback questioning.

Client demonstrated insight into impact of these experiences on their emotional, cognitive, and

behavioral experiences.

Phase 2

Therapist used EMDR Therapy Phase 2 to review client’s internal and external resources,

as well as discuss current management of stressors and triggers. Can also add: Client

created/strengthened their (identify resource) with bilateral dual attention stimulus (DAS).

Document any other therapeutic skill, tool, or approach you use here for preparation work.

Sample response: Client initially struggled with learning a deep breathing strategy then was able
to complete and reported a pleasant response after making some modifications to count.

Responded affirmatively to the Light Stream guided visualization with addition of bilateral dual

attention stimulus, reporting pleasant sensations and showing positive affect overall.

Phase 3 (if target is NOT completed in session)

EMDR Therapy Phases 3-4 used to begin/continue reprocessing first/worst/most recent

floatback target for negative cognition/blocking belief related to value/responsibility/ power and

control/emotional expression/etc. Document beginning SUD = , VOC = . 132 DOCUMENTING

EMDR THERAPY SESSIONS [con’t] Sample response: Client was able to tolerate (and reduce)

emotional distress during reprocessing with fast dual attention stimulus. End SUD = . Phase 7

used to debrief and reduce residual emotional distress after reprocessing. List any resources

accessed, such as breathing strategies, grounding strategies, etc.

Phases 3-7 (if target is completed in session)

EMDR Therapy Phases 3-7 used to begin/continue reprocessing first/worst/most recent

floatback target for negative cognition/blocking belief related to value/responsibility/ power and

control/emotional expression/etc. Beginning SUD = , VOC = . Sample response: Client was able

to tolerate and reduce emotional distress during reprocessing with fast dual attention stimulus.

Positive belief installed with adaptive/ clear body scan.

Phase 7 used to debrief reprocessing, discuss any identified concerns and insights, and

plan for next session.

 Phase 8 If checking back in on a previous target: Therapist used EMDR Therapy Phase 8

to check back in on previous reprocessing. (Positive belief held/SUD = .) If conducing treatment

plan re-evaluation or review: Reviewed Phase 1 Client History in the context of progress made

thus far on established target to determine new goals and directions for treatment. (NOTE:

Adjust new goals or interventions on treatment plan as needed) Sample response: Client agreed

that initial goal of improving mood and increasing effectiveness at work was met. Began

discussing next goals for treatment related to addressing relational issues; identified a new set of

potential targets for addressing this goal.

Flash:

Therapist used Flash Technique (FT) with client. Client was able to reduce emotional

distress with fast dual attention blinking of eyes. Client started SUD at an 8 and ended at a 0.

Clinician and client completed Flash Technique (FT). Therapist used with client. Client

was able to reduce emotional distress with fast dual attention blinking of eyes. Client's beginning

SUD = 8. Client's ending SUD = 0. Client was practice memory reconsolidation. Client focused

on a positive scene and clinician periodically visually disrupted client's concentration on that

positive scene using a series of guided and rapid blinks. Client was able to tolerate this several

rapid blinks (once every five seconds for a duration of 30 seconds). The therapist verified that

the positive scene was in focus and was not intersecting with the negative memory in any way.

The memory was briefly reactivated and the calm scene with blinks repeats. Over the course of
10¬30 minutes, this cycle of blinking in the calm scene and periodically reevaluating the changes

in the memory occurred. The process helps move the memory from hot and activated memory

space into more normal and less activated memory storage. Four Blinks Flash was Developed by

Thomas Zimmerman

ITP ideas:

1. Develop a vocabulary to describe depression, Identify cues and symptoms, Identify

areas of vulnerability which underlie depression, Identify triggers to these areas. Identify

antecedents, triggers, and consequences to acting out on depression

2. Accept that clients depression is causing problems, Link cues and symptoms of

depression with triggers and with harmful coping behaviors, Identify issues contributing to

depression

3. Use the support of counselor and others — and reduce isolation and avoidance.

4. Identify specific areas of cognitive distortion, Challenge irrational thoughts with

reality, Develop appropriate substitute self-statements for irrational ones.

5. Without chemicals or other dependency-related “coping” behaviors, client will engage

in behavioral activation activities.

 6. Learn coping techniques to reduce depression, Identify appropriate responses to

feelings of depression, Learn relaxation techniques to reduce depression, Develop alternative

responses to substitute for past “coping” choices

7. Develop vocabulary to describe anxiety, fears, and sadness, Identify cues and symptoms,

Identify areas of vulnerability which underlie anxiety, Identify triggers to these areas,

Identify antecedents, triggers, and consequences to acting out on anxiety.

8. Identify specific areas of cognitive distortions and thinking errors, Challenge irrational

thoughts with reality, Develop appropriate substitute self-statements and behaviors for

irrational ones

9. Identify appropriate response to feelings of anxiety and depression, Learn relaxation

techniques to reduce anxiety (thought stopping, thought switching, creative visualization,

progressive muscle relaxation, deep breathing, ect.), Develop alternative responses to

substitute for past “coping” choices.

10. Increase understanding of relationship between underlying vulnerability, triggers,

feelings, thoughts, choices or behaviors., Increase understanding of pattern or “cycle” of

problem behaviors, leading to acting out.

11. Identify specific issues causing anxiety/depression, and maladaptive controlling

behaviors used to address these feelings.

12. Client rates depression at 10/10 and would like to reduce it down to 5//10 in the next 3

months.

13. Client would like to learn 10 emotional regulation skills in the next 3 months to reduce

the frequency and intensity of anxiety and depression in the next 3 months.