Copline form test page Copline Form Date Month Day Year Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneHighest EdHSAABAMAPhDSession Time SAME Treatment GoalReduce StressReduce PanicReduce PTSDReduce DepressionUnresolved TraumaReduce PTSD SymptomsDecrease Panic AttacksIncrease Social FunctioningDiagnosisPanicMajor DepressionPTSDSingleRecurrentAdjustment DisorderOtherDiagnosis – Other LocationIn OfficePhoneVideoOtherLocation – Other Termination Goal Learn triggers to dx & deal appropriately w/ stressors Return to pre-incident functioning level Decrease at-risk behavior, impulsivity Increase communication, set boundaries Present Illness ChecklistPost Traumatic Stress Disorder Recurrent and intrusive distressing recollections of the event Recurrent distressing dreams of the event Acting or feeling as if the traumatic event were recurring, such as flashbacks Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Efforts to avoid thoughts, feelings, or conversations associated with the trauma Efforts to avoid activities, places or people that arouse recollections of the trauma Inability to recall an important aspect of the trauma Markedly diminished interest or participation in significant activities Feeling of detachment or estrangement from others Restricted range of affect Sense of foreshortened future Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or more With delayed onset: if onset of symptoms is at least 6 months after the stressor Depression Sad / Empty / Teary Problem sleeping / # of hours Changes in appetite / weight change Changed in energy Changes in interest / motivation Feeling agitation Problems concentrating / focusing Feelings of persistent guilt Suicidal thoughts / intent / attempts Others: Helplessness / Overwhelmed Anxiety Restless / agitated / afraid Feeling dizzy / lightheaded / faint / spacey Throat tightness Chest tightness / palpitations Shortness of breath Abdominal discomfort / nausea Shaking / tingling / numbness Sweats / chills Others: Anxiety – Other: Adjustment Disorders Marked distress that is in excess of what would be expected from exposure to the stressor Significant impairment in social or occupational (academic) functioning Acute: Symptoms are less than 6 months Chronic: Symptoms are more than 6 months Other Possible Diagnoses & SymptomsPresenting Situation & Intervention Concrete problem solving, i.e. guided imagery, role playing Cognitive refocusing of thoughts, resilience training, mindfulness Used psychotherapeutic techniques to deal with stressors from the past that affect his/her present Need for outside activities to reduce stress and improve coping Response(response options will be provided below once a selection is made) Patient is unable to use techniques due to: Patient is using techniques with Patient is unable to use techniques due to:Patient is using techniques with Limited success Some success Success All the time PrognosisGoodFairPoorPatient: Decompensates quickly High at risk behavior Lethality Patient: is making progress and gaining insight is not making progress and gaining insight Patient: is decompensating only holding his / her own at this time Present MedicationsMedicationsDosageTime / DayHow TakenLast Time Taken Significant Medical & Psychosocial HistoryRisk Factors Sex Gambling Drugs Prescription Drugs Alcohol Food Tobacco Gaining Insight Used for Coping Social with a Hx of abuse Other Notes Any hospitalizations? Yes No Where / WhenHomicidal risk? Yes No Relapses Yes No Notes > 1 Month > 2 Months > 3 Months < 3 Months < 6 Months < 9 Months < 12+ Months 12 Step program Suicide / Self Harm Assessment FormDenies at this timePassiveSuicidalThought Process, Including the Ability to Express Needs and Respond to QuestionsHis / Her thoughts are: Agitated Clear Persevering Hypervigilant Insightful Distracted Scattered He / She was not able to express his/her needs in session with guidance, refocusing respond to questions in out of treatment. Guarded, Abrasive at time. Plan for Next Session:Plan In-Patient Referral Follow-up this week Follow-up next week Other Plan – Other Life Threatening – needs to be seen immediately Emergency – needs to be referred for intensive services Deal with stressorsSevereHighMediumLow
