Name: Judy A.

Sample
1/26/2016

ID: 1
Page #: 1

SSN: 555-55-5555

Birthday: 7/7/1946

Date:

Clinical Record
Name:

Judy A. Sample

Provider:

Default Provider

Date:1/26/2016

Personal Data
ID: 1
Address: 111 Main St.
City:
State/Province:
Zip/Postal Code:
Home Phone:
Work Phone:
SSN:

Anywhere
MI
11111
(555)555-5555
(555)555-5555
555-55-5555

Birth Date:
Age:
Gender:
Race:
Marital Status:
Military Rank:
Treatment Start Date:
Treatment End Date:
Last Review:

Treatment Status:
Previously Treated?:
Pri. Care Physician:
Employer:
Referral Source:
Psychiatrist:
Setting:
Department:

7/7/1946
69
Female
Caucasian
Married
NA
8/7/2006

Active
No
Dr Smith
Sue Jackson
Outpatient
East Paris

Authorization Data
Insurance Carrier
Aetna

Date Authorized
8/7/2006

Total Sessions Authorized This Episode:

Start Date
8/7/2006

End Date
11/7/2006
Sessions Used:

Authorized Sessions
6

Authorization Number
989887

Sessions Remaining:

Assessment
Interviewer:

Default Provider

Interview Date:

8/7/2006

Person Interviewed:

Patient

Psychosocial History:
Family:

Judy indicates that her father was an anxious man who worried about everything. Judy was close to him while she
lived at home. Judy has been married to Bob for 40 years and they have two daughters who are married and live
close to Judy. She has a good relationship with her husband and her daughters. Judy enjoys working in her garden
but would like to entertain her friends more if she was not so preoccupied with worry.
Developmental:

N/A
Substance Use:

Judy denies any problems with use of alcohol or other mood altering drugs. There is no history of substance use
disorder in her family of origin nor with her husband.
Socio-Economic:

Judy and Bob live alone in their own home. Bob is employed as engineer at a large corporation. Judy was working as
a school secretary until two years ago when she quit due to her overwhelming worries. She denies any significant
financial problems but she does worry about their retirement finances. She and Bob attend church services quite
regularly but she fears that God does not hear her prayers for peace of mind.
Psychiatric:

Judy has never been in counseling before but her father was admitted to a psychiatric hospital one time for about two
weeks several years ago. Judy has been on Xanax from her Ob-Gyn physician, Dr. Cole, for several months.
Medical:

Judy complains of severe pain her back that has been with her for two years. She has been told that surgery will not
help. She worries that it may be something serious like cancer that has not been found.

Name: Judy A. Sample

1/26/2016

Strengths/Weaknesses

ID: 1
Page #: 2

SSN: 555-55-5555

Birthday: 7/7/1946

Strengths:
Stable Work History, Positive Support Network, Motivated for Change
Weaknesses:
Poor Health, Indecisive

Assessments Completed:
Instrument/Interview: Clinical Interview
Date Administered: 8/7/2006
Result:
Details:

Data Source: Patient

Treatment Phase:

Instrument/Interview: Psychosocial History

Date Administered: 8/7/2006
Data Source: Patient
Result:
Treatment Phase:
Details:
Instrument/Interview: Global Severity Index
Date Administered: 8/7/2006
Data Source: Patient
Result: 22.00
Treatment Phase: Pre-Treatment
Details:
Instrument/Interview: Global Severity Index
Date Administered: 8/14/2006
Data Source: Patient
Result: 11.00
Treatment Phase: During Treatment
Details:
Instrument/Interview: Global Severity Index
Date Administered: 9/11/2006
Data Source: Patient
Result: 7.00
Treatment Phase: Post-Treatment
Details:

Interpretation Note:

Mental Status:
Presentation

Date First Rated: 8/7/2006

Appearance:
Mood:
Attitude:
Affect:
Speech:
Motor Activity:
Orientation:

Mental Functioning
Simple Calculations:
Serial Sevens:
Immediate Memory:
Remote Memory:
General Knowledge:
Proverb Interpretation:
Similarities/Differences:

Higher Order Abilities

Judgment:

Date Last Rated:

Well-Groomed
Anxious
Cooperative
Appropriate
Pressured
Tense
Fully Oriented
Date First Rated: 8/7/2006

Date Last Rated:

Accurate
Accurate
Intact
Intact
Accurate
Accurate
Accurate
Date First Rated: 8/7/2006
Intact

Date Last Rated:

Date:

Name: Judy A. Sample

1/26/2016
Insight:
Intelligence:

Thought Form/Content
Thought Processes:
Delusions:
Hallucinations:

Risk Assessment

ID: 1
Page #: 3
Intact
High

SSN: 555-55-5555

Birthday: 7/7/1946

Date First Rated: 8/7/2006

Date Last Rated:

Logical and Organized

None Evident
None Evident
Date First Rated: Date Last Rated:

Suicide:
Violence:
Child Abuse:
Partner Abuse:
Elder/Parent Abuse:

Latest Note:

8/7/2006
None
None
None
None
None

Most Recent Mental Status Summary:

Recovery Assessment ASAM Patient Placement Criteria 2R:

Date: 8/21/2006
Six Dimensions
I.
Acute Intoxication and/or Withdrawal Potential
II.
Biomedical Conditions & Complications
III.
Emotional / Behavioral or Cognitive Conditions & Complications
IV.
Readiness to Change
V.
Relapse, Continued Use or Continued Problem Potential
VI.
Recovery / Living Environment
Level of Care:
Comment:

Severity
Medium
Low
High
Medium
Low
High

Level IV, Medically-Managed Intensive Inpatient Treatment

Recovery Assessment Stage of Change:

Problem: Anxiety
Date Assessed
8/7/2006

Stage of Change
Preparation

Problem: Chronic Pain

Date Assessed
Stage of Change
8/7/2006
Pre-contemplation

Comment

Comment

Diagnosis
Axis I

300.02

Generalized Anxiety Disorder

Axis II

V71.09

No Diagnosis

Axis III
Axis IV
Axis V

Chronic Back Pain

Health
Current: 51-60 Prior: 81-90
Stress Severity Rating: Moderate

Treatment Techniques
Treatment Modalities:
CPT Code
90806

Type
Indiv. OP Psychotherapy-45" no Med. Eval

Frequency
1 Weekly

Provider
Default Provider

Date:

Name: Judy A. Sample

1/26/2016
Recommended
Level of care
Outpatient

ID: 1
Page #: 4
Least Restrictive
Alternative?
Yes

SSN: 555-55-5555

Agreement with
level of care?
Yes

Birthday: 7/7/1946

Date:

Is recommended level
of care available?
Yes

Treatment Approaches:
The following treatment approaches are being implemented:
Cognitive Restructuring, Behavioral Techniques
Medication: Xanax
Start Date: 8/7/2006
Note:

Dosage: 5mg.
End Date:

Frequency: 1x/day
Prescribed by: Dr.Jones

Presenting Problems
Primary Anxiety
Secondary Chronic Pain

Treatment Plan
Primary Problem:
Behavioral Definition

Anxiety

Excessive and/or unrealistic worry that is difficult to control occurring more days than not for at least 6 months about a
number of events or activities.
Motor tension (e.g., restlessness, tiredness, shakiness, muscle tension).
Autonomic hyperactivity (e.g., palpitations, shortness of breath, dry mouth, trouble swallowing, nausea, diarrhea).
Hypervigilance (e.g., feeling constantly on edge, experiencing concentration difficulties, having trouble falling or staying
asleep, exhibiting a general state of irritability).

Long-term Goals

Reduce overall frequency, intensity, and duration of the anxiety so that daily functioning is not impaired.

Short-Term Objectives/Therapeutic Interventions

Describe current and past experiences with the worry and anxiety symptoms, complete with their impact on functioning
and attempts to resolve it.
Assess the focus, excessiveness, and uncontrollability of the client's worry and the type, frequency,
intensity, and duration of her anxiety symptoms (e.g., The Anxiety Disorders Interview Schedule for the
DSM-IV by DiNardo, Brown, and Barlow).
Verbalize an understanding of the cognitive, physiological, and behavioral components of anxiety and its treatment.
Discuss how generalized anxiety typically involves excessive worry about unrealistic threats, various
bodily expressions of tension, overarousal, and hypervigilance, and avoidance of what is threatening that
interact to maintain the problem (see Mastery of Your Anxiety and Worry - Therapist Guide by Craske,
Barlow, and O'Leary).
Assign the client to read psychoeducational sections of books or treatment manuals on worry and
generalized anxiety (e.g., Mastery of Your Anxiety and Worry - Client Guide by Zinbarg, Craske, Barlow,
and O'Leary).
Discuss how treatment targets worry, anxiety symptoms, and avoidance to help the client manage worry
effectively and reduce overarousal and unnecessary avoidance.
Learn and implement calming skills to reduce overall anxiety and manage anxiety symptoms.
Teach the client relaxation skills (e.g., progressive muscle relaxation, guided imagery, slow diaphragmatic
breathing) and how to discriminate better between relaxation and tension; teach the client how to apply
these skills to her daily life (e.g., Progressive Relaxation Training by Bernstein and Borkovec; Treating
GAD by Rygh and Sanderson).
Assign the client homework each session in which she practices relaxation exercises daily; review and

Name: Judy A. Sample

1/26/2016

ID: 1
Page #: 5

SSN: 555-55-5555

Birthday: 7/7/1946

Date:

reinforce success while providing corrective feedback toward improvement.

Use biofeedback techniques to facilitate the client's success at learning relaxation skills.
Assign the client to read about progressive muscle relaxation and other calming strategies in relevant books
or treatment manuals (e.g., Progressive Relaxation Training by Bernstein and Borkovec; Mastery of Your
Anxiety and Worry - Client Guide by Zinbarg, Craske, Barlow, and O'Leary).
Verbalize an understanding of the role that cognitive biases play in excessive irrational worry and persistent anxiety
symptoms.
Assist the client in analyzing her fear by examining the probability of the negative expectation occurring,
the real consequences of it occurring, her ability to control the outcome, the worst possible outcome, and
her ability to accept it (see "Analyze the Probability of a Feared Event" in Adult Psychotherapy Homework
Planner, 2nd ed. by Jongsma, and Anxiety Disorders and Phobias by Beck and Emery).
Assigned homework for Journal and Replace Self-Defeating Thoughts
Identify, challenge, and replace biased, fearful self-talk with positive, realistic, and empowering self-talk.
Explore the client's schema and self-talk that mediate her fear response; challenge the biases; assist her in
replacing the distorted messages with reality-based alternatives and positive self-talk that will increase her
self-confidence in coping with irrational fears.
Teach the client to implement a thought-stopping technique (thinking of a stop sign and then a pleasant
scene) for worries that have been addressed but persist (or assign "Making Use of the Thought-Stopping
Technique" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma); monitor and encourage the
client's use of the technique in daily life between sessions.
Assigned homework for Making Use of the Thought-Stopping Technique
Undergo gradual repeated imaginal exposure to the feared negative consequences predicted by worries and develop
alternative reality-based predictions.
Direct and assist the client in constructing a hierarchy of two to three spheres of worry for use in exposure
(e.g., worry about harm to others, financial difficulties, relationship problems).
Select initial exposures that have a high likelihood of being a success experience for the client; develop a
plan for managing the negative affect engendered by exposure; mentally rehearse the procedure.
Assign the client a homework exercise in which she does worry exposures and records responses (see
Mastery of Your Anxiety and Worry - Client Guide by Zinbarg, Craske, Barlow, and O'Leary or
Generalized Anxiety Disorder by Brown, O'Leary, and Barlow); review, reinforce success, and provide
corrective feedback toward improvement.
Maintain involvement in work, family, and social activities.
Support the client in following-through with work, family, and social activities rather than escaping or
avoiding them to focus on panic.

Secondary Problem:
Behavioral Definition

Chronic Pain

Has decreased or stopped activities such as work, household chores, socializing, exercise, sex, or other pleasurable
activities because of pain.
Makes statements like "I can't do what I used to"; "No one understands me"; "Why me?"; "When will this go away?"; "I
can't take this pain anymore"; and "I can't go on."
Complains of generalized pain in many joints, muscles, and bones that debilitates normal functioning.

Long-term Goals

Regulate pain in order to maximize daily functioning and return to productive employment.

Short-Term Objectives/Therapeutic Interventions

Describe the nature of, history of, impact of, and understood causes of chronic pain.
Assess the history and current status of the client's chronic pain.
Explore the changes in the client's mood, attitude, social, vocational, and familial/marital roles that have
occurred as a result of the pain.
Complete a thorough medication review by a physician who is a specialist in dealing with chronic pain or headache
conditions.
Ask the client to complete a medication review with a specialist in chronic pain or headaches; confer with
the physician afterward about her recommendations and process them with the client.

Name: Judy A. Sample

1/26/2016

ID: 1
Page #: 6

SSN: 555-55-5555

Birthday: 7/7/1946

Date:

Participate in a cognitive behavioral group therapy for pain management.

Form a small, closed enrollment group (4-8 clients) for pain management (see Group Therapy for Patients
with Chronic Pain by Keefe, Beaupre, Gil, Rumble, and Aspnes).
Identify and monitor specific pain triggers.
Teach the client self-monitoring of her symptoms; ask the client to keep a pain journal that records time of
day, where and what she was doing, the severity, and what was done to alleviate the pain (or assign "Pain
and Stress Journal" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma); process the journal
with the client to increase insight into nature of the pain, cognitive, affective, and behavioral triggers, and
the positive or negative effect of the interventions they are currently using.
Learn and implement somatic skills such as relaxation and/or biofeedback to reduce pain level.
Teach the client relaxation skills (e.g., progressive muscle, guided imagery, slow diaphragmatic breathing)
and how to discriminate better between relaxation and tension; teach the client how to apply these skills to
her daily life (see Progressive Relaxation Training by Bernstein and Borkovec).
Identify areas in the client's life that she can implement skills learned through relaxation or biofeedback.
Assign a homework exercise in which the client implements somatic pain management skills and records
the result; review and process during the treatment session.
Assign the client to read about progressive muscle relaxation and other calming strategies in relevant books
or treatment manuals (e.g., Progressive Relaxation Training by Bernstein and Borkovec).
Identify negative pain-related thoughts and replace them with more positive coping-related thoughts.
Explore the client's schema and self-talk that mediate her pain response, challenging the biases; assist her in
generating thoughts that correct for the biases, facilitate coping, and build confidence in managing pain.
Assign the client a homework exercise in which she identifies negative pain-related self-talk and positive
alternatives (or assign "Journal and Replace Self-Defeating Thoughts" in Adult Psychotherapy Homework
Planner, 2nd ed. by Jongsma); review and reinforce success, providing corrective feedback toward
improvement.
Assign the client to read about cognitive restructuring in relevant books or treatment manuals (e.g., The
Chronic Pain Control Workbook by Catalano and Hardin).
Integrate and implement new mental, somatic, and behavioral ways of managing pain.
Assist client in integrating learned pain management skills (e.g., relaxation, distraction, activity scheduling)
into a progressively wider range of daily activities; record and review.

Response to Plan
Response to treatment plan presentation:
Significant Other response to treatment plan presentation:
I, Judy A. Sample, have reviewed this treatment plan.
x. _______________________________________________

Date: ______________________________

Progress Notes
Session 1

Date: 8/7/2006
Time: 9:00 AM to 10:00 AM
Modality: Individual Psychotherapy

(60 min)

Progress Rating: Some Progress

CPT Code:

Narrative Progress Note:

Judy has shared her symptoms of anxiety. She experinces worry surrounding her safety but cannot explain why she should feel
so threatened. She is afraid to make many decisons as she fears some dire consequence. She is tense and feels nauseous often.

Provider Signature:

1/26/2016
Date

Default Provider

Session 2

Date: 8/14/2006
Time: 9:00 AM to 10:00 AM
Modality: Individual Psychotherapy

(60 min)

Progress Rating:
CPT Code:

Name: Judy A. Sample

1/26/2016

ID: 1
Page #: 7

SSN: 555-55-5555

Birthday: 7/7/1946

Date:

Problem Addressed: Anxiety

Patient Presentation (Signs and Symptoms):
The client related that she is constantly feeling on edge, that sleep is interrupted, and that concentration is difficult.
The client described a history of restlessness, tiredness, muscle tension, and shaking.
The client reported the presence of symptoms such as heart palpitations, dry mouth, tightness in the throat, and some shortness of
breath.
Interventions Implemented:
The client was taught about how anxious fears are maintained by a cycle of unwarranted fear and avoidance that precludes
positive, corrective experiences with the feared object or situation.
A discussion was held about how treatment targets worry, anxiety symptoms, and avoidance to help the client manage worry
effectively.
Problem Addressed: Chronic Pain
Patient Presentation (Signs and Symptoms):
The client has complained of pain throughout her body and in many joints, muscles, and bones.
The client has significantly decreased or stopped activities related to work, household chores, socialization, exercise, and sexual
pleasure because of pain.
The client made frequent pessimistic verbalizations about her inability to control the pain or live a normal life or be understood
by others.
Interventions Implemented:
A history of the client's experience of chronic pain and her associated medical conditions was gathered.
The changes in the client's social, vocational, familial, and intimate life that have occurred in reaction to her pain were explored.
Narrative Progress Note:
Provider Signature:

1/26/2016
Date

Default Provider

Session 3

Date: 8/23/2006
Time: 9:00 AM to 9:30 AM
Modality: Individual Psychotherapy

Progress Rating: No Change

CPT Code:

(30 min)

Narrative Progress Note:

Provider Signature:
Default Provider

1/26/2016
Date

Objective Ratings
Objectives Identified
Describe current and past experiences with the worry and anxiety symptoms, complete
with their impact on functioning and attempts to resolve it.
Verbalize an understanding of the cognitive, physiological, and behavioral components
of anxiety and its treatment.
Learn and implement calming skills to reduce overall anxiety and manage anxiety
symptoms.
Verbalize an understanding of the role that cognitive biases play in excessive irrational
worry and persistent anxiety symptoms.
Identify, challenge, and replace biased, fearful self-talk with positive, realistic, and
empowering self-talk.
Undergo gradual repeated imaginal exposure to the feared negative consequences
predicted by worries and develop alternative reality-based predictions.
Maintain involvement in work, family, and social activities.
Describe the nature of, history of, impact of, and understood causes of chronic pain.
Complete a thorough medication review by a physician who is a specialist in dealing
with chronic pain or headache conditions.
Participate in a cognitive behavioral group therapy for pain management.
Identify and monitor specific pain triggers.
Learn and implement somatic skills such as relaxation and/or biofeedback to reduce
pain level.

Critical?
No

First Progress
Rating:
8/7/2006
No Change

Last Progress
Rating:
8/23/2006
No Change

No

No Change

No Change

No

No Change

No Change

No

No Change

No Change

No

No Change

No Change

No

No Change

No Change

No
No
No

No Change
No Change
No Change

No Change
No Change
No Change

No
No
No

No Change
No Change
No Change

No Change
No Change
No Change

Name: Judy A. Sample

ID: 1
SSN: 555-55-5555
1/26/2016
Page #: 8
Identify negative pain-related thoughts and replace them with more positive copingrelated thoughts.
Integrate and implement new mental, somatic, and behavioral ways of managing pain.

Birthday: 7/7/1946
No

No Change

No Change

No

No Change

No Change

Date:

Prognosis
Prognosis Rating of successful achievement of Goals: Good
Rationale for Prognosis Rating:

Judy is strongly motivated to work on her issues and she has a good support network.

Discharge
Discharge Criteria:

Mood, behavior and thought stabilized sufficiently to independently carry out basic self-care.

Verbalizes names of supportive resources who can be contacted if feeling suicidal/homicidal.

Hallucinations or delusions controlled enough to not interfere with basic self-care.

Referral Made To:
After-care Plan/ Discharge Summary:

Provider Credentials

Primary Treatment Provider

Default Provider

Supervisor
Default Provider

License:

License:

Treatment Team: Clinical Staff

Default Provider

Requested Amendments
Request Date: 8/7/2006
Section: Progress
Reason for Denial:
Person Approving/Denying: Jongsma, Arthur E (PhD)
Amendment:

Approved: Yes
Person Requesting:

Approve/Deny Date: 8/7/2006

Judy Sample

Judy wants to point out that she has always been tense and fearful.

Disclosure Authorizations
Patient was provided PHI Privacy Notice: Yes
Patient signed PHI Privacy Acknowledgement: Yes
Patient Has Not Signed but Receipt of Form was Witnessed: No
Date: 8/7/2006

Purpose: Provision of PHI to other professionals

Authorization on File:
Address:

General Notes

Yes

To Whom:

Bill Allen
City: Fastoo

What Disclosed: All Protected Health Information except

Psychotherapy Notes
Agency: Fastoo CMH
State: MI
ZIP: 49525

Name: Judy A. Sample

1/26/2016

ID: 1
Page #: 9

SSN: 555-55-5555

Birthday: 7/7/1946

Date: