CLIENT VISIT NOTES

Client Name:     Date:

DX:     Session #:     CPT Code:

Present in Session:


Client's Presenting Concerns:

Symptoms:

Note severity and whether targeted in session for those symptoms present.


Depressed Mood

Insomnia

Hypersomnia

Weight Loss/Gain

Psychomotor Agitation/Retardation

Fatigue / Loss of Energy

Difficulty Concentrating

Indecisiveness

Hopelessness

Low Self-Esteem

Recurring Thoughts of Death

Suicidal Ideation

Suicide Plan

Suicide Attempt

Self-Injurious Behavior

Homicidal Ideation

Anxiety / Worry

Panic Attacks

Phobia

Obsessive Thoughts

Compulsive Behavior

Irritability

Angry Outbursts

Hypomania / Mood Swings

Relationship Problems

Withdrawal / Isolation

Impaired Social Skills

Substance Abuse

Problems with Work Performance

Problems with Academic Performance

ADHD (Inattentive/Hyperactive)

Perceptual Disturbance

Memory Disturbance

Impaired Judgement

Restricting Food Intake

Overeating

Binge / Purge

Medical Concerns

Exaggerated Startle Response

Restricted Range of Affect

Restlessness or Feeling Keyed Up

Hypervigilance

Muscle Tension

Recurrent Distressing Recollections / Dreams

Anhedonia

Somatic Complaints

Other:

Notes:

Medication(s)/Dosage(s):

Treatment Plan:

Homework:

Treatment(s) Utilized:

Assessment

Behavioral Approach

Cognitive Restructuring

Collateral Contact

Couples / Family

DBT Therapy

Desensitization

Emotional Processing

Individual Therapy

Insight-Oriented

Play Therapy

Psycho-Education

Skills Training

Solution Focused

Stress Management

Other:



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