A New Way CBRS Evaluation Note

A New Way Counseling CBRS Note H2017
Client Full Name*
First NameLast Name
Hours*
Date*
MonthDayYear
Time*
:HourMinutesAM/PM Option
until
until :HourMinutesAM/PM Option
LOCATION*
Client homeRetail StoreProfessional ServicesParking GarageMedical FacilityProfessional OfficePublic ParkPublic LibraryPolice/Sheriff OfficeOther
Location(if other)
Issue*
PsychiatricMedicalFinancialSocialFamilyBasic Living SkillsHousingVocational/EducationCommunity/Legal
Presentation*
CooperativeGood MoodHappyAngryAnxiousAttention SeekingDefensiveDepressedDistractedIrritableLethargicOppositionalOverwhelmedParanoidPassiveResistantSadUnfocusedWithdrawnOther
If other describe
Techniques and Interventions CBRS provided:
Active Listening/ReflectionAnger ManagementAppropriate BoundariesBreathing TechniquesBudgetingCBT InterventionsCharting and LogsCoachingCommunication between client and medical providerCommunication skillsConflict Resolution SkillsCoping StrategiesCrisis PlanDBT exercises for mindfulnessDBT InterventionDecompensation, skills to identifyExpression of feelings in an appropriate mannerFamilial ConflictGoal SettingHygieneIdentification of personal strengths and weaknessesImpulsivityInnapropriate Use of LanguageInterpersonal skillsIn-vivo exerciseJournalingMeditation techniquesModelingProblem solvingPro-social behaviorProvided supportRapport building/maintenanceRedirectedReviewedRole-playedSelf-calming techniquesSelf-care techniquesSelf-control techniquesStress management techniquesSymptom IdentificationThinking errorsValidation
WORKBOOKS/CURRICULUM
Subjective/Objective*
Service Provided *
Risk Assessment*
NOT considered to be a significantly elevated risk for self harm or harm to others.SOME suicidal thoughts or thoughts of self harm, however there are sufficient barriers in place to prevent self injury. Does not require more intense services.ELEVATED risk for self harm or harm to others.
Client Response*
Client reported understanding of the information taught.Client actively engaged in session with CBR SpecialistResponded positively to CBR SpecialistResistant while working with CBR SpecialistOppositional, feeling that the information did not pertain to client.Difficult to engage in the therapeutic process.
Plan*
Client will need additional instruction and training before the client will be able to implement the skills into his or her daily routine.Additional practice is needed to help the client implement skills practiced into his or her daily routine.Needs a moderate amount of additional training before the client will be able to implement skills into his or her daily routine.Will be able to implement skills practiced into daily routine without additional instruction
Worker Name & Title*
Rosemary DeMeter-Gietzen PA, LSW (LSW-31669)Janice Carter BSTonya Ward BSSarah Cathcart BS, CBRSJoni Kuhlman BAJordan Forde, BAMelanie Stacey BSJennifer Larsen, LCSW QSUDPFrances Lands, LCSW, CADC, CCSCraig Cumber, MSEric Scott, BSCheryl Smith, LSW
Review date*
Next appointment*
Should be Empty:

A New Way Counseling CBRS Note H2017