Mental Health

Conduct comprehensive mental health intake for [new patient]:

Patient: [age, gender]
Presenting problem: [chief complaint]
Referral source: [self, physician, court, etc.]
Previous treatment: [history]
Current stressors: [life circumstances]
Support system: [family, friends]

Intake assessment:
- Presenting problem (onset, duration, severity, triggers)
- Mental health history (diagnoses, hospitalizations, suicide attempts)
- Current symptoms (mood, anxiety, psychosis, trauma)
- Psychiatric medications (current and past, response)
- Substance use history (type, frequency, last use, treatment)
- Medical history (conditions affecting mental health)
- Family psychiatric history
- Social history (relationships, employment, living situation)
- Trauma history (ACEs, abuse, violence)
- Developmental history (milestones, school)
- Legal history (arrests, probation, custody)
- Mental status exam
- Risk assessment (suicide, homicide, self-harm)
- Strengths and protective factors
- Diagnostic impressions (provisional)
- Treatment recommendations
- Safety planning
- Prognosis

Assess suicide risk for [patient]:

Patient: [demographics]
Presenting concern: [what prompted assessment]
Current mood: [affect and statements]
Recent stressors: [triggering events]
Prior attempts: [history]
Support: [who's available]

Suicide risk assessment:
- Suicidal ideation (frequency, intensity, duration)
- Intent (desire to die vs ambivalence)
- Plan (specific method, access to means)
- Prior attempts (lethality, recency)
- Risk factors (depression, hopelessness, isolation, substance use, impulsivity)
- Warning signs (giving away possessions, saying goodbye)
- Protective factors (reasons for living, support, religion, children)
- Access to lethal means
- Substance use status
- Mental status (judgment, insight, impulse control)
- Risk level (low, moderate, high, imminent)
- Hospitalization need (voluntary vs involuntary)
- Safety planning (crisis resources, coping skills, support contacts)
- Means restriction counseling
- Follow-up plan (when, with whom)
- Family/support notification with consent
- Documentation of rationale

Develop mental health treatment plan for [diagnosis]:

Patient: [demographics]
Diagnosis: [DSM-5 diagnosis]
Symptoms: [current symptoms]
Impairment: [functional impact]
Patient goals: [what they want to achieve]
Treatment modality: [individual, group, family]

Treatment plan:
- Problem list (prioritized)
- Diagnosis with specifiers
- Long-term goals (measurable, achievable)
- Short-term objectives (steps to goals, SMART)
- Interventions by modality:
  - Individual therapy (frequency, type)
  - Group therapy (specific groups)
  - Family therapy
  - Medication management
  - Case management
- Therapeutic approach (CBT, DBT, psychodynamic, etc.)
- Frequency and duration of services
- Prognosis
- Barriers to treatment
- Progress monitoring methods
- Discharge criteria
- Coordination with other providers
- Patient agreement and signature

Create crisis intervention plan for [patient]:

Patient: [demographics]
Diagnosis: [conditions]
Crisis history: [what typically happens]
Triggers: [what precipitates crisis]
Warning signs: [early indicators]
Support system: [who can help]

Crisis plan:
- Patient's description of crisis
- Early warning signs (thoughts, feelings, behaviors)
- Internal coping strategies (what patient can do):
  - Distraction techniques
  - Self-soothing
  - Grounding exercises
  - Safe activities
- Support contacts:
  - Name, phone, when to call
  - Reasons to reach out
- Professional contacts:
  - Therapist contact
  - Psychiatrist contact
  - Crisis hotline (988)
  - Emergency room
- Reasons for living (personal motivations)
- Safety environment (means restriction)
- What others can do to help
- When to use emergency services
- Post-crisis follow-up plan
- Review and update schedule

Document therapy session note:

Patient: [identifier]
Session number: [X of treatment]
Modality: [individual, group, family]
Duration: [minutes]
Therapy type: [CBT, DBT, etc.]

Therapy note:
- Subjective (patient report of mood, events, symptoms)
- Objective:
  - Mental status (appearance, mood, affect, thought process)
  - Topics discussed
  - Interventions used
  - Patient engagement and participation
  - Skills practiced
  - Homework review
- Assessment:
  - Progress toward goals
  - Symptom changes (improvement, worsening, stable)
  - Barriers to progress
  - Risk status
  - Response to interventions
- Plan:
  - Homework assigned
  - Skills to practice
  - Next session focus
  - Medication management coordination
  - Referrals if needed
  - Next appointment
- Risk assessment if clinically indicated

Design CBT intervention for [presenting problem]:

Problem: [depression, anxiety, etc.]
Target symptoms: [specific symptoms]
Patient insight: [understanding of problem]
Cognitive patterns: [thinking errors]
Behavioral patterns: [avoidance, etc.]
Motivation: [readiness]

CBT intervention:
- Psychoeducation (CBT model explanation)
- Thought monitoring (identify automatic thoughts)
- Cognitive restructuring:
  - Identify cognitive distortions
  - Evidence for and against thoughts
  - Alternative balanced thoughts
  - Thought records
- Behavioral activation:
  - Activity scheduling
  - Pleasant events
  - Graded task assignment
- Exposure hierarchy (if anxiety):
  - Fear ladder
  - Gradual exposure plan
  - Response prevention
- Homework assignments
- Skills practice
- Relapse prevention
- Measuring outcomes
- Session structure and frequency

Assess substance use disorder:

Patient: [demographics]
Substance(s): [what they use]
Frequency: [how often]
Last use: [when]
Reason for assessment: [what prompted]
Motivation: [readiness to change]

Substance use assessment:
- Substances used (including alcohol, prescriptions)
- Pattern of use (frequency, amount, route)
- Age of first use
- Progression of use over time
- Longest period of sobriety
- DSM-5 criteria assessment (11 criteria)
  - Control impairment
  - Social impairment
  - Risky use
  - Pharmacological indicators
- Severity (mild 2-3, moderate 4-5, severe 6+ criteria)
- Consequences (health, legal, financial, relationships, work)
- Tolerance and withdrawal symptoms
- Prior treatment attempts (what worked, what didn't)
- Co-occurring mental health disorders
- Medical complications
- Motivation and readiness to change (stages of change)
- Treatment recommendations (level of care)
- Recovery support system
- Barriers to treatment

Develop trauma-focused treatment for [trauma type]:

Trauma: [type and timing]
Symptoms: [PTSD symptoms present]
Safety: [current safety status]
Prior treatment: [trauma therapy history]
Stabilization: [coping skills, support]
Readiness: [for trauma processing]

Trauma treatment plan:
- Phase 1 - Stabilization:
  - Safety assessment and planning
  - Psychoeducation (trauma response, PTSD)
  - Emotion regulation skills
  - Grounding techniques
  - Distress tolerance
  - Establishing safety and trust
- Phase 2 - Trauma Processing (when stable):
  - Trauma narrative development
  - Exposure therapy (imaginal and in vivo)
  - EMDR if appropriate
  - Cognitive processing (stuck points)
  - Meaning making
- Phase 3 - Integration:
  - Reconnection with life
  - Relationships and intimacy
  - Identity beyond trauma
  - Post-traumatic growth
- Co-occurring issues (substance use, depression)
- Pacing (patient-driven)
- Between-session support
- Crisis planning for activation

Create mental health discharge summary:

Patient: [demographics]
Admission date: [date]
Discharge date: [date]
Length of stay/treatment: [duration]
Treatment setting: [inpatient, IOP, outpatient]
Reason for discharge: [goals met, insurance, etc.]

Discharge summary:
- Admission diagnosis
- Presenting problems at admission
- Treatment provided:
  - Therapy modality and frequency
  - Medications (started, adjusted, discontinued)
  - Groups attended
  - Milestones achieved
- Progress toward goals (measurable outcomes)
- Discharge diagnosis
- Current mental status
- Current medications with instructions
- Discharge recommendations:
  - Continuing care plan (outpatient provider)
  - Medication management follow-up
  - Support groups (AA, NAMI, etc.)
  - Skills to continue practicing
  - Warning signs to monitor
  - Crisis resources
- Prognosis
- Follow-up appointments scheduled
- Barriers to ongoing care identified
- Releases signed for coordination of care