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Header Information
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Telepsychiatry
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Date of initial consult or first appt with you :
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Session Number (1 through 12)
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Session #6 Recap?
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Recap Therapy Goal(s) and Progress:
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History of the Present Illness:
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Client Quote:
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HPI free text:
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Depression
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Anxiety
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ADHD
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Bipolar
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PTSD
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OCD
• • •
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Borderline Personality
• • •
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Narcissitic Personality
• • •
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Disordered Eating
• • •
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Alcohol/ Illicit Drug/Medication Assessment:
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Client Denies Alcohol/Illicit Drug Use:
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If no, please specify substance, frequency, amount:
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Current Medication:
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Medication Side Effects:
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If Medication Side Effects, explain:
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EVALUATE PATIENT FOR TMS AND CBH
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MSE:
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Appearance:
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A & O:
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Behavior:
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Speech:
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Affect:
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TP:
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Judgement
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Insight
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Mood
• • •
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Pt subjective quote about Mood:
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SI:
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SI
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Contracts for Safety
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HI
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HI
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Psychosis
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Specify psychotic symptoms
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PHQ-9
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PHQ-9 Score
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GAD-7
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GAD-7 Score
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Y-BOCS
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Y-BOCS Score
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PCL-5
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PCL-5 Score
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WHO-5
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WHO-5 Score
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Diagnostic Impression:
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DI: Major Depressive Disorder
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DI: Bipolar
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Anxiety Disorders:
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DI- Substance Use Disorders:
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DI- ADHD
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DI: Eating Disorders
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DI: Personality Disorders
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DI: Cognition
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DI: Other Disorders
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Other Disorder/Rule-Outs: (If not listed previously)
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Referrals:
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TMS Discussed?
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If TMS discussed, explain:
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Clear Behavioral Center Discussed?
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If CBH was discussed, explain:
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Client referred to CCC to/for:
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Progress/Assessment/Treatment Planning:
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Assessement:
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Therapeutic Intervention Used
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Problem List
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Descriptive Therapeutic Technique Used
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Other Problems (not listed):
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Targeted Goals:
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Pt Progressing with therapy:
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EVIDENCE OF PROGRESS OR NOT
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Therapy treatment plan:
• • •
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Homework Assignments:
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Additional treatment plans:
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Termination Session?
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Follow Up:
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CPT
• • •
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Psychotherapy Start Time:
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End Time (MUST BE 53-60 MINUTES):
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Risks/Benefits Statement
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Supervisor:
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