2014
Completed the fake anger management class they sent me to in January. Waste of my life what a sick joke that these people play on citizens.
I remember going to see my uncle Dave in the hospital and talking with a family. Close with these people they don't like the way I talk or how open I am. Remember telling them telling me that my father was supposed to come back and play some music for my uncle while he was dying. Was really drugged up and he couldn't speak at all or open his eyes you could just hear him struggling to breathe when you were talking to him like he was getting emotional and wanted to wake up but he wasn't too much pain and couldn't.
I remember standing in the backyard and Warren telling my father how much it would have been to his brother if he went there and played the guitar one last time because they used to play in a little band together. I kept telling everybody about this, In the end my dad and his best friend Rick Moran did go to the hospital and played the guitar for my uncle Dave and they said that they saw tears in his eyes. And that makes me want to cry and it makes me happy at the same time it's sad that he was dying but happy that his brother was there in the end doing something that they loved together.
Uncle Dave passed away on November 22nd 2014 12th
Link to BHN mental health records for 2014-2015
https://rickystebbins78.blogspot.com/2025/06/2014-2015-behavioral-health-network.html
Records copied and pasted for Ai
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Olabisi, Olushola (004185)
Document Date: 2/3/2014
Client Program: (Not Set)
Transition/Discharge Summary/Plan
Type of Request: Transition
Discharge
Discharging From: BHN Center for WellBeing--Springfield
Admission Date:
Last Contact:
Transition/Discharge
Date: 02/03/2014
Person's location and contact information post discharge/transition
Address: Unknown
Country: United States of America
Street 1: 54 Hope Street
Street 2:
APT/Suite:
City: Springfield
State/Province: MA
Postal Code: 01119
County/Region: Hampden
Telephone: Unknown
Summary of Services/
Treatment Provided/
Status at Last Contact:
Richard was called for appoitment but he did not call back
Outcomes(Include
qualitative and
quantitative information
regarding progress/
gains achieved,
strengths, abilities and
preferences.Specify any
standardized measures
used):
Sobriety Status/
Description of Current
Drug or Alcohol Use:
Not applicable
Status Towards Meeting Goals(NM=Not Met, PM=Partially Met, M=Met, D/
C=Discontinued)
Keyword Status Comments
Overall Progress In
Treatment: intake not shown
Behavioral Health Network, Inc. -
Outpatient Transfer/Discharge Form
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Diagnosis At Intake: Langlands, Rebecca (003566) - No DSM Code (1/14/2014)
Diagnosis At Discharge: Langlands, Rebecca (003566) - No DSM Code (1/14/2014)
Reason for Transition or
Discharge: Decrease level of care
Increase level of care
Goals met, no services needed
Person terminated services
Person refused referral for other
services
Involuntary discharge, person
informed of right to appeal
Person died
Person moved
Person did not return/was non-
responsive to outreach attempts
Other
If involuntary/
administratively
discharged, summary of
action taken:
Not applicable
Person Served notified
of appeal process: Yes
No
Person's Response to
Treatment and
Transition/Discharge:
Medications as
Reported by Person at
time of Transition/
Discharge:
None Reported
Medication Name Dose Plans for Change -
Including Rate of Detox Prescribed by
Referred To (Agency/Program
Name, Location, and Contact
Information)
For (describe services/supports,
rationale, list dates/times of
appointments if known)
Date(s) of Appts. If Known
Aftercare Options
(Include information on
symptoms person
should watch for,
options available if
these symptoms recur
or additional services
needed):
Was person provided
copy of Transition/
Discharge Plan?
Yes, Person given copy
Yes, Person mailed copy
No, Person did not receive copy(explain):
the writer could not contact Richard
Program Management
Effective Date/Time: Enter the date and time for the change
02/03/2014
09:24 AM
Behavioral Health Network, Inc. -
Outpatient Transfer/Discharge Form
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
Type of Request: Refer to Additional Program
Transfer to another Program and/or Staff
Discharge from Program
Discharge from Episode/Organization
Episode: Outpatient Services
Program(s) Discharging
from: Day Treatment (DAYTX), Outpatient (OP)
Reason: Person did not return/was non-responsive to outreach attempt
Signatures
Signature #1: Olushola Olabisi (Masters +2, Masters) - 2/3/2014 9:25 AM
Signature #2: Jeffrey P. Kassis (LICSW) - 2/3/2014 2:51 PM
Signature History
Action Date Staff
Document Signed 2/3/2014 Olushola Olabisi
(Masters +2, Masters)
Document Signed 2/3/2014 Jeffrey P. Kassis
(LICSW)
Behavioral Health Network, Inc. -
Outpatient Transfer/Discharge Form
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Document Date: 3/16/2015
Client Program: Outpatient (OP)
Transition/Discharge Summary/Plan
Type of Request: Transition
Discharge
Discharging From: BHN Center for WellBeing--Springfield
Admission Date: 06/25/2014
Last Contact: 03/16/2015
Transition/Discharge
Date: 03/16/2015
Person's location and contact information post discharge/transition
Address: Unknown
Country: United States of America
Street 1: 176 South St
Street 2:
APT/Suite: B
City: West Warren
State/Province: MA
Postal Code: 01092
County/Region: Worcester
Telephone: Unknown
Summary of Services/
Treatment Provided/
Status at Last Contact:
Client was self referred per the advise of the doctors at Baystate. Therapist
worked with client and provided Psychotherapy, care coordination, Psychiatric
referrals and medication managment.
Outcomes(Include
qualitative and
quantitative information
regarding progress/
gains achieved,
strengths, abilities and
preferences.Specify any
standardized measures
used):
BPRS, client reports that his medications are able to calm him down and reports
significant improvement in the mood
Sobriety Status/
Description of Current
Drug or Alcohol Use:
Not applicable
Status Towards Meeting Goals(NM=Not Met, PM=Partially Met, M=Met, D/
C=Discontinued)
Keyword Status Comments
Person Served will establish
chemical dependence recovery that M client is regularly attending his
psychiatric appointments and is
Behavioral Health Network, Inc. -
Outpatient Transfer/Discharge Form
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
leads to improved physical and
ment.. complaint with the recommendation
Richard will decrease his anxiety
syptoms PM Client needs to maintain OP
services and requested for the one
closer to his place of residence
Overall Progress In
Treatment: Client has been able to stabilize with the administration of the current medication
and is able to establish working relationship with his providers. Client reports, "the
services helped calm my mind"
Diagnosis At Intake: Adhikari, Radha (004049) - No DSM Code (1/13/2015)
Diagnosis At Discharge: Adhikari, Radha (004049) - No DSM Code (2/10/2015)
Reason for Transition or
Discharge: Decrease level of care
Increase level of care
Goals met, no services needed
Person terminated services
Person refused referral for other
services
Involuntary discharge, person
informed of right to appeal
Person died
Person moved
Person did not return/was non-
responsive to outreach attempts
Other
Client requested referral to Carson Center at Ware
If involuntary/
administratively
discharged, summary of
action taken:
Not applicable
Person Served notified
of appeal process: Yes
No
Person's Response to
Treatment and
Transition/Discharge:
Discharge planning done as per the request of the client
Medications as
Reported by Person at
time of Transition/
Discharge:
None Reported
Medication Name Dose Plans for Change -
Including Rate of Detox Prescribed by
Referred To (Agency/Program
Name, Location, and Contact
Information)
For (describe services/supports,
rationale, list dates/times of
appointments if known)
Date(s) of Appts. If Known
Carson Center for Human Services OP services unknown at the time of the
documentation
Aftercare Options
(Include information on
symptoms person
should watch for,
options available if
these symptoms recur
or additional services
needed):
This writer left a VM at the intake coordinator's desk to assist with the referral
process. Client will consider walking in the clinic after this writer is able to make
the referral with specific informations. Per supervision notes, client will continue
to see the med provider "Regina Sanders" at this clinic until another psychiatric
appointment is established in Carson Center.
Behavioral Health Network, Inc. -
Outpatient Transfer/Discharge Form
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
Was person provided
copy of Transition/
Discharge Plan?
Yes, Person given copy
Yes, Person mailed copy
No, Person did not receive copy(explain):
Discharge planning done collaboratively in the presence of the client.
Program Management
Effective Date/Time: Enter the date and time for the change
03/16/2015
11:11 AM
Type of Request: Refer to Additional Program
Transfer to another Program and/or Staff
Discharge from Program
Discharge from Episode/Organization
Program Discharging
from: Outpatient (OP)
Reason: Other
Signatures
Signature #1: Radha Adhikari (Masters +2) - 3/18/2015 4:13 PM
Signature #2: Mark Augarten (LICSW) - 3/23/2015 11:44 AM
Signature History
Action Date Staff
Document Signed 3/16/2015 Radha Adhikari (Masters
+2)
Document Signed 3/18/2015 Radha Adhikari (Masters
+2)
Document Signed 3/18/2015 Radha Adhikari (Masters
+2)
Document Signed 3/23/2015 Mark Augarten (LICSW)
Behavioral Health Network, Inc. -
Outpatient Transfer/Discharge Form
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Davenport, Leslie (005406)
Document Date: 12/14/2015
Client Program: (Not Set)
Transition/Discharge Summary/Plan
Type of Request: Transition
Discharge
Discharging From: BHN Center for WellBeing--Springfield
Admission Date:
Last Contact: 7/30/15
Transition/Discharge
Date: 12/14/2015
Person's location and contact information post discharge/transition
Address: Unknown
Country: United States of America
Street 1: 176 South St
Street 2:
APT/Suite: B
City: West Warren
State/Province: MA
Postal Code: 01092
County/Region: Worcester
Telephone: Unknown
Summary of Services/
Treatment Provided/
Status at Last Contact:
Richard completed a CA during his tx episode a LSC and met with his therapist
one time.
Outcomes(Include
qualitative and
quantitative information
regarding progress/
gains achieved,
strengths, abilities and
preferences.Specify any
standardized measures
used):
N/A
Sobriety Status/
Description of Current
Drug or Alcohol Use:
Not applicable
Status Towards Meeting Goals(NM=Not Met, PM=Partially Met, M=Met, D/
C=Discontinued)
Keyword Status Comments
NM N/A
Behavioral Health Network, Inc. -
Outpatient Transfer/Discharge Form
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Overall Progress In
Treatment: N/A
Diagnosis At Intake: Andrews, Meghan (004365) - No DSM Code (6/25/2014)
Diagnosis At Discharge: Davenport, Leslie (005406) - No DSM Code (7/30/2015)
Reason for Transition or
Discharge: Decrease level of care
Increase level of care
Goals met, no services needed
Person terminated services
Person refused referral for other
services
Involuntary discharge, person
informed of right to appeal
Person died
Person moved
Person did not return/was non-
responsive to outreach attempts
Other
If involuntary/
administratively
discharged, summary of
action taken:
Not applicable
Person Served notified
of appeal process: Yes
No
Person's Response to
Treatment and
Transition/Discharge:
N/A
Medications as
Reported by Person at
time of Transition/
Discharge:
None Reported
Medication Name Dose Plans for Change -
Including Rate of Detox Prescribed by
Referred To (Agency/Program
Name, Location, and Contact
Information)
For (describe services/supports,
rationale, list dates/times of
appointments if known)
Date(s) of Appts. If Known
N/A N/A N/A
Aftercare Options
(Include information on
symptoms person
should watch for,
options available if
these symptoms recur
or additional services
needed):
N/A
Was person provided
copy of Transition/
Discharge Plan?
Yes, Person given copy
Yes, Person mailed copy
No, Person did not receive copy(explain):
Richard did not respond to outreach attempts/re-engagement.
Program Management
Effective Date/Time: Enter the date and time for the change
12/14/2015
Behavioral Health Network, Inc. -
Outpatient Transfer/Discharge Form
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
11:37 AM
Type of Request: Refer to Additional Program
Transfer to another Program and/or Staff
Discharge from Program
Discharge from Episode/Organization
Program Discharging
from: Outpatient (OP)
Reason: Person did not return/was non-responsive to outreach attempt
Signatures
Signature #1: Leslie Davenport (Masters +2) - 12/14/2015 11:39 AM
Signature #2: Mark Augarten (LICSW) - 12/14/2015 3:14 PM
Signature History
Action Date Staff
Document Signed 12/14/2015 Leslie Davenport
(Masters +2)
Document Signed 12/14/2015 Mark Augarten (LICSW)
Behavioral Health Network, Inc. -
Outpatient Transfer/Discharge Form
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Sanders, Regina (002736)
Service Date/Time: 10/31/2014 10:40 AM
- 11:00 AM
Client Program: Medication Clinic (MED)
Activity: Evaluation & Management (E&M)
Payer: Tufts Health Together MCO(TuftsHT)
Procedure Code: 99213 : SA
Units: 1.00
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychiatry Note E&M
Persons Present: Richard
Chief Complaint: I feel the same- no different
Interval HPI: Mood- irritable
thoughts- racing, intusive thoughts to hurt someone- no plan
Pertinent Medical,
Social and Family
History:
Lives with mother & sister, separated from current wife
divorced from 1st wife # children- no contact
was student at scc- has not worked recently does not have SSI
as a child I went to counseling- they thought I had ADHD- Im pretty sure I was on
ritalin- stopped in forth grade- I was awful in school- I threw water on the floor to
see kids fall down, I picked on people
2004- was separating from 1st wife- drank gallons of alcohol passed out for 24
hrs- developed rhabdomyelosis hosp for 2 ICU then 1 wk APTU escaped from
aptu- went back was released took 100 xtra strength tylenol "felt better" was not
hospitalized
around 29 tried counseling mood was changing down all the time for reason
wing, griswold - was prescribed diffent medication "none worked"
Medication History: Depakote
ritalin
Key Testing/Lab
Results: CMP- wnl except sl elevated BUN 21
CBC wnl
VPA 55.5
Review of Systems: "i have tendonitis all over- I hjave soft tisue damage all over the doctors cant
figure ot what it is they say its in my head"
r rotatocuff injury when hit- 3 surguries became imfected still not right
orthoscopic sugery on l wrist
fell and head last summer- passed out from pain-large scar on r temple states he
did not have concussion
r knee orthoscopis surgery r knee-
Other Systems
Reviewed and Negative: Yes
Medical Conditions: Does person served have any medical conditions that required consideration in
prescribing (i.e. pregnancy, diabetes, etc.)?
Yes
No
E &M Mental Status Exam
General Appearance/
Hygiene/Build: WNL
Comments: tense
Eye Contact/Attention/
Concentration: WNL
Comments: intense
Gait/Station/Body WNL
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 1 of 5 Date Printed: 3/26/2025 3:42 PM
Movement:
Comments:
Muscle Strength/Tone/
AIMS: WNL
Comments:
Behavior: WNL
Comments: irritable
Speech/Language: WNL
Comments:
Self-Reported Mood: WNL
Comments: irritable, rageful
Emotional State-Affect: WNL
Comments: congruent
Hallucinations: None Noted None Reported
Comments:
Delusions: None Noted None Reported
Comments:
Thought Content: WNL
Comments:
Thought Process: WNL
Comments:
Associations: WNL
Comments:
Self-Injurious Thoughts: WNL
Comments:
Suicidal Thoughts: WNL
Comments: passing
Aggressive Thoughts: WNL
Comments: yes- to get revenge hurt people for not doing what he thinks they are supposed to
do
Cognitive Functioning/
Fund of Knowledge: WNL Intellectual Disability Other, describe
Comments:
Orientation: WNL
Disoriented to: Person
Place
Situation Time
Comments:
Memory: WNL
Comments:
Insight: WNL
Comments: fair
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 2 of 5 Date Printed: 3/26/2025 3:42 PM
Judgment: WNL
Comments: fair
Impulsivity: None Noted None Reported
Comments: see intake, very much so
Comments:
Vitals Entry
Date: 11/03/2014
01:26 PM
Unable to Collect:
Blood Pressure: Systolic
Diastolic
Heart Rate:
Respiration Rate:
Temperature: Fahrenheit
Source of Height/Weight: Gathered Directly
Height: Field accepts inches only - be sure to convert feet to inches
72
Weight: Pounds
212
BMI: 28.75
Pain Scale:
Client Medications
Begin Date End Date Amount/Refills Status
10/31/2014 (Not Set) 60/0 Active
Medication and Dosage: Risperdal (risperidone) 2 mg tablet 1 tablet
Sig: Take 1 tablet by mouth twice a day
10/31/2014 (Not Set) 60/0 Active
Medication and Dosage: Depakote (divalproex) 250 mg tablet,delayed release (DR/EC) 1 tablet
Sig: 1 tablet by mouth twice a day
10/24/2014 10/31/2014 60/0 Inactive
Medication and Dosage: Risperdal (risperidone) 1 mg tablet 1 tablet
Sig: Take 1 tablet by mouth twice a day
10/24/2014 10/31/2014 60/0 Inactive
Medication and Dosage: Depakote (divalproex) 500 mg tablet,delayed release (DR/EC) 1 tablet
Sig: Take 1 tablet by mouth twice a day
Client DSM Diagnosis as of 10/31/2014
Client: Stebbins, Richard (110100) 10/8/1978
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 3 of 5 Date Printed: 3/26/2025 3:42 PM
Date Diagnosed: 10/31/2014
Diagnosis By: Sanders, Regina (002736)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1 r/o psychosis
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
301.9 - Personality Disorder
NOS 301.9 - PERSONALITY
DISORDER NOS 2 cluster b , predominant
borderline traits but also
antisocial, and narcissistic
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Severe
Problems with access to health care services Mild feels the doctors are not treating his muscle
pain
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 46
Impression/Plan
Impression: Not a danger to self or others at this time.Denies plan or intent to act on angry
feelings Mood d/o nos
Problems/Plans: (Include information about problem status, interventions)
mood- irritable angry labile increase depakote to 750mg BID
thoughts- remain angry- increase risperdal to 2 mg BID
reviewed with Dr Subramanyam
Reviewed Medications
With Person/Guardian: Explained rationale for medication choices, reviewed mixture of medications,
discussed possible risks, benefits, effectiveness (if applicable) and alternate
treatment with person/guardian?
Yes
No
Person: Understands
Information
Does Not Understand
Information
Agrees With Medication
Refuses Medication
Other
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 4 of 5 Date Printed: 3/26/2025 3:42 PM
Guardian: Understands
Information
Does Not Understand
Information
Agrees With Medication
Refuses Medication
Other
Comments:
Psychotherapy
Delivered? No Yes
Return To Clinic In: 1 wk
Additional Services
Setting: Inpatient
Outpatient
SNF/ALF
Client Status: New Patient Existing Patient Consultation
Was >50% of time
used for
counseling:
Yes
No
Total
Psychotherapy
time (minutes):
Evaluation and Management Calculator
History Type Exam Type MDM Type
None None None
Problem Focused Problem Focused Straightforward
Expanded Problem
Focused Expanded Problem
Focused Low Complexity
Detailed Detailed Moderate Complexity
Comprehensive Comprehensive High Complexity
E/M Level: 3
Educational Materials
Were any educational
materials given to
person today?
Yes
No
Signatures
Signature #1: Regina Sanders (APRN/NP) - 11/3/2014 1:41 PM
Signature History
Action Date Staff
Document Signed 11/3/2014 Regina Sanders (APRN/
NP)
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 5 of 5 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Sanders, Regina (002736)
Service Date/Time: 12/3/2014 9:20 AM
- 9:40 AM
Client Program: Medication Clinic (MED)
Activity: Evaluation & Management (E&M)
Payer: Tufts Health Together MCO(TuftsHT)
Procedure Code: 99213 : SA
Units: 1.00
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychiatry Note E&M
Persons Present: Richard
Chief Complaint: I feel awful I sit around and feel like killing myself-I dont have a plan but every
time I think of killing myself I feel better. Taking 1mg of Risperdal twice a day,
Depakote 500mg BID, again ( previously at this dose he stated he felt no different
which is why it was increased last visit then he c/o side effects in the interim and
it was loweredd back to original dose - which he now states is causing increased
suicidal behavior) I dont think of homicide any more and Im not as irritable -
maybe thats why
Interval HPI: Mood- depressed not as irritable
thoughts- still racing think of hurting self but dont tink of hurting other people
appetite good
sleep - good
Pertinent Medical,
Social and Family
History:
Lives with mother & sister, separated from current wife
divorced from 1st wife # children- no contact
was student at scc- has not worked recently does not have SSI
as a child I went to counseling- they thought I had ADHD- Im pretty sure I was on
ritalin- stopped in forth grade- I was awful in school- I threw water on the floor to
see kids fall down, I picked on people
2004- was separating from 1st wife- drank gallons of alcohol passed out for 24
hrs- developed rhabdomyelosis hosp for 2 ICU then 1 wk APTU escaped from
aptu- went back was released took 100 xtra strength tylenol "felt better" was not
hospitalized
around 29 tried counseling mood was changing down all the time for reason
wing, griswold - was prescribed diffent medication "none worked"
Medication History: Depakote
ritalin
risperdal
Key Testing/Lab
Results: CMP- wnl except sl elevated BUN 21
CBC wnl
VPA 55.5 on 500 BID
Review of Systems: "i have tendonitis all over- I hjave soft tisue damage all over the doctors cant
figure ot what it is they say its in my head"
r rotatocuff injury when hit- 3 surguries became imfected still not right
orthoscopic sugery on l wrist
fell and head last summer- passed out from pain-large scar on r temple states he
did not have concussion
r knee orthoscopis surgery r knee-
Other Systems
Reviewed and Negative: Yes
Medical Conditions: Does person served have any medical conditions that required consideration in
prescribing (i.e. pregnancy, diabetes, etc.)?
Yes
No
E &M Mental Status Exam
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 1 of 5 Date Printed: 3/26/2025 3:42 PM
General Appearance/
Hygiene/Build: WNL
Comments:
Eye Contact/Attention/
Concentration: WNL
Comments: intense
Gait/Station/Body
Movement: WNL
Comments:
Muscle Strength/Tone/
AIMS: WNL
Comments:
Behavior: WNL
Comments:
Speech/Language: WNL
Comments:
Self-Reported Mood: WNL
Comments: depressed
Emotional State-Affect: WNL
Comments: constricted
Hallucinations: None Noted None Reported
Comments:
Delusions: None Noted None Reported
Comments:
Thought Content: WNL
Comments: negative "I think how squandered my life", intrusive
Thought Process: WNL
Comments: racing
Associations: WNL
Comments:
Self-Injurious Thoughts: WNL
Comments:
Suicidal Thoughts: WNL
Comments: states constantly - no specific plan no intent
Aggressive Thoughts: WNL
Comments: have diminished greatly
Cognitive Functioning/
Fund of Knowledge: WNL Intellectual Disability Other, describe
Comments:
Orientation: WNL
Disoriented to: Person
Place
Situation Time
Comments:
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 2 of 5 Date Printed: 3/26/2025 3:42 PM
Memory: WNL
Comments:
Insight: WNL
Comments: poor
Judgment: WNL
Comments: poor
Impulsivity: None Noted None Reported
Comments: in past none reported at this time
Comments:
Vitals Entry
Date: 12/03/2014
10:32 AM
Unable to Collect:
Blood Pressure: Systolic
Diastolic
Heart Rate:
Respiration Rate:
Temperature: Fahrenheit
Source of Height/Weight: Gathered Directly
Height: Field accepts inches only - be sure to convert feet to inches
72
Weight: Pounds
212
BMI: 28.75
Pain Scale:
Client Medications
Begin Date End Date Amount/Refills Status
12/3/2014 (Not Set) 30/1 Active
Medication and Dosage: olanzapine (olanzapine) 10 mg tablet 1 tablet
Sig: 1 tablet by mouth at bedtime
11/19/2014 (Not Set) 60/1 Active
Medication and Dosage: Depakote (divalproex) 500 mg tablet,delayed release (DR/EC) 1 tablet
Sig: 1 tablet by mouth twice a day
11/19/2014 (Not Set) 60/1 Active
Medication and Dosage: benztropine (benztropine) 1 mg tablet 1 tablet
Sig: Take 1 tablet by mouth every evening as needed
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 3 of 5 Date Printed: 3/26/2025 3:42 PM
10/31/2014 12/3/2014 60/1 Inactive
Medication and Dosage: Risperdal (risperidone) 2 mg tablet 1 tablet
Sig: Take 1 tablet by mouth twice a day
Client DSM Diagnosis as of 12/3/2014
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 12/3/2014
Diagnosis By: Sanders, Regina (002736)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1 r/o psychosis
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
301.9 - Personality Disorder
NOS 301.9 - PERSONALITY
DISORDER NOS 2 cluster b , predominant
borderline traits but also
antisocial, and narcissistic
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Severe
Problems with access to health care services Mild feels the doctors are not treating his muscle
pain
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 46
Impression/Plan
Impression: Not a danger to self or others at this time.Denies plan or intent to act on angry
feelings Mood d/o nos
Problems/Plans: (Include information about problem status, interventions)
mood- depressed not as irritable continue depakote at 500mg BID
racing thoughts - d/c risperdal start Zyprexa 10mg po QHS
reviewed crisis # in case of increased SI
Reviewed Medications
With Person/Guardian: Explained rationale for medication choices, reviewed mixture of medications,
discussed possible risks, benefits, effectiveness (if applicable) and alternate
treatment with person/guardian?
Yes
No
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 4 of 5 Date Printed: 3/26/2025 3:42 PM
Person: Understands
Information
Does Not Understand
Information
Agrees With Medication
Refuses Medication
Other
Guardian: Understands
Information
Does Not Understand
Information
Agrees With Medication
Refuses Medication
Other
Comments:
Psychotherapy
Delivered? No Yes
Return To Clinic In: 1 mo
Additional Services
Setting: Inpatient
Outpatient
SNF/ALF
Client Status: New Patient Existing Patient Consultation
Was >50% of time
used for
counseling:
Yes
No
Total
Psychotherapy
time (minutes):
Evaluation and Management Calculator
History Type Exam Type MDM Type
None None None
Problem Focused Problem Focused Straightforward
Expanded Problem
Focused Expanded Problem
Focused Low Complexity
Detailed Detailed Moderate Complexity
Comprehensive Comprehensive High Complexity
E/M Level: 3
Educational Materials
Were any educational
materials given to
person today?
Yes
No
Signatures
Signature #1: Regina Sanders (APRN/NP) - 12/3/2014 10:37 AM
Signature History
Action Date Staff
Document Signed 12/3/2014 Regina Sanders (APRN/
NP)
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 5 of 5 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Sanders, Regina (002736)
Service Date/Time: 1/7/2015 11:30 AM
- 12:00 PM
Client Program: Medication Clinic (MED)
Activity: Evaluation & Management (E&M)
Payer: Tufts Health Together MCO(TuftsHT)
Procedure Code: 99213 : SA
Units: 1.00
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychiatry Note E&M
Persons Present: richard
Chief Complaint: I still have suicidal thoughts not tired, noticed when the other one wore off ( I
have less anxiety) When something gets me mad I get like road rage but not on
the road. Meds dont work therapy doesn't do anything
Interval HPI: Mood- depressed suicidal thoughts
thoughts- suicidal thoughts I thought how much easier my life would be if I was
dead. I want help I want these to go away
appetite "I eat on schedule"
sleep - good, "I dont dream"
Pertinent Medical,
Social and Family
History:
Lives with mother & sister, separated from current wife
divorced from 1st wife # children- no contact
was student at scc- has not worked recently does not have SSI
as a child I went to counseling- they thought I had ADHD- Im pretty sure I was on
ritalin- stopped in forth grade- I was awful in school- I threw water on the floor to
see kids fall down, I picked on people
2004- was separating from 1st wife- drank gallons of alcohol passed out for 24
hrs- developed rhabdomyelosis hosp for 2 ICU then 1 wk APTU escaped from
aptu- went back was released took 100 xtra strength tylenol "felt better" was not
hospitalized
around 29 tried counseling mood was changing down all the time for reason
wing, griswold - was prescribed diffent medication "none worked"
Medication History: Depakote
ritalin
risperdal
Key Testing/Lab
Results: CMP- wnl except sl elevated BUN 21
CBC wnl
VPA 55.5 on 500 BID
Review of Systems: "i have tendonitis all over- I hjave soft tisue damage all over the doctors cant
figure ot what it is they say its in my head"
r rotatocuff injury when hit- 3 surguries became imfected still not right
orthoscopic sugery on l wrist
fell and head last summer- passed out from pain-large scar on r temple states he
did not have concussion
r knee orthoscopis surgery r knee-
Other Systems
Reviewed and Negative: Yes
Medical Conditions: Does person served have any medical conditions that required consideration in
prescribing (i.e. pregnancy, diabetes, etc.)?
Yes
No
E &M Mental Status Exam
General Appearance/
Hygiene/Build: WNL
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 1 of 5 Date Printed: 3/26/2025 3:42 PM
Comments:
Eye Contact/Attention/
Concentration: WNL
Comments:
Gait/Station/Body
Movement: WNL
Comments:
Muscle Strength/Tone/
AIMS: WNL
Comments:
Behavior: WNL
Comments: irritable, challenging
Speech/Language: WNL
Comments:
Self-Reported Mood: WNL
Comments: depressed
Emotional State-Affect: WNL
Comments: irritable
Hallucinations: None Noted None Reported
Comments:
Delusions: None Noted None Reported
Comments: has paranoid delusions
Thought Content: WNL
Comments: negativity
Thought Process: WNL
Comments: racing. disconected
Associations: WNL
Comments:
Self-Injurious Thoughts: WNL
Comments:
Suicidal Thoughts: WNL
Comments: "constantly"
Aggressive Thoughts: WNL
Comments: all day I don't act on it
Cognitive Functioning/
Fund of Knowledge: WNL Intellectual Disability Other, describe
Comments:
Orientation: WNL
Disoriented to: Person
Place
Situation Time
Comments:
Memory: WNL
Comments:
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 2 of 5 Date Printed: 3/26/2025 3:42 PM
Insight: WNL
Comments:
Judgment: WNL
Comments:
Impulsivity: None Noted None Reported
Comments:
Comments:
Vitals Entry
Date: 01/07/2015
11:50 PM
Unable to Collect:
Blood Pressure: Systolic
Diastolic
Heart Rate:
Respiration Rate:
Temperature: Fahrenheit
Source of Height/Weight: Gathered Directly
Height: Field accepts inches only - be sure to convert feet to inches
72
Weight: Pounds
212
BMI: 28.75
Pain Scale:
Client Medications
Begin Date End Date Amount/Refills Status
1/7/2015 (Not Set) 30/0 Active
Medication and Dosage: olanzapine (olanzapine) 15 mg tablet 1 tablet
Sig: 1 tablet by mouth at bedtime
12/3/2014 1/7/2015 30/1 Inactive
Medication and Dosage: olanzapine (olanzapine) 10 mg tablet 1 tablet
Sig: 1 tablet by mouth at bedtime
11/19/2014 (Not Set) 60/1 Active
Medication and Dosage: Depakote (divalproex) 500 mg tablet,delayed release (DR/EC) 1 tablet
Sig: 1 tablet by mouth twice a day
11/19/2014 (Not Set) 60/1 Active
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 3 of 5 Date Printed: 3/26/2025 3:42 PM
Medication and Dosage: benztropine (benztropine) 1 mg tablet 1 tablet
Sig: Take 1 tablet by mouth every evening as needed
Client DSM Diagnosis as of 1/7/2015
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 1/7/2015
Diagnosis By: Sanders, Regina (002736)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1 r/o psychosis
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
301.9 - Personality Disorder
NOS 301.9 - PERSONALITY
DISORDER NOS 2 cluster b , predominant
borderline traits but also
antisocial, and narcissistic
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Severe
Problems with access to health care services Mild feels the doctors are not treating his muscle
pain
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 46
Impression/Plan
Impression: Not a danger to self or others at this time.Denies plan or intent to act on angry
feelings Mood d/o nos
Problems/Plans: (Include information about problem status, interventions)
mood- depressed not as irritable continue depakote at 500mg BID
racing irritable continues Zyprexa 15mg po QHS
reviewed crisis # in case of increased SI
Reviewed Medications
With Person/Guardian: Explained rationale for medication choices, reviewed mixture of medications,
discussed possible risks, benefits, effectiveness (if applicable) and alternate
treatment with person/guardian?
Yes
No
Person: Understands Information Does Not Understand
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 4 of 5 Date Printed: 3/26/2025 3:42 PM
Information
Agrees With Medication
Refuses Medication Other
Guardian: Understands
Information
Does Not Understand
Information
Agrees With Medication
Refuses Medication
Other
Comments:
Psychotherapy
Delivered? No Yes
Return To Clinic In: 1 mo
Additional Services
Setting: Inpatient
Outpatient
SNF/ALF
Client Status: New Patient Existing Patient Consultation
Was >50% of time
used for
counseling:
Yes
No
Total
Psychotherapy
time (minutes):
Evaluation and Management Calculator
History Type Exam Type MDM Type
None None None
Problem Focused Problem Focused Straightforward
Expanded Problem
Focused Expanded Problem
Focused Low Complexity
Detailed Detailed Moderate Complexity
Comprehensive Comprehensive High Complexity
E/M Level: 3
Educational Materials
Were any educational
materials given to
person today?
Yes
No
Details: medication explanation
explanation of DBT
Signatures
Signature #1: Regina Sanders (APRN/NP) - 1/8/2015 12:00 AM
Signature History
Action Date Staff
Document Signed 1/8/2015 Regina Sanders (APRN/
NP)
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 5 of 5 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Sanders, Regina (002736)
Service Date/Time: 2/4/2015 2:00 PM
- 2:20 PM
Client Program: Medication Clinic (MED)
Activity: Evaluation & Management (E&M)
Payer: Tufts Health Together MCO(TuftsHT)
Procedure Code: 99213 : SA
Units: 1.00
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychiatry Note E&M
Persons Present: richard
Chief Complaint: I dont think the meds are helping my mind races, still feel depressed feel like
hurting myself- try to get my mind out of that thought process
Interval HPI: Mood- depressed suicidal thoughts
thoughts- racing suicidal
appetite "I eat on schedule"
sleep - good, "I dont dream"
Pertinent Medical,
Social and Family
History:
Lives with mother & sister, separated from current wife
divorced from 1st wife # children- no contact
was student at scc- has not worked recently does not have SSI
as a child I went to counseling- they thought I had ADHD- Im pretty sure I was on
ritalin- stopped in forth grade- I was awful in school- I threw water on the floor to
see kids fall down, I picked on people
2004- was separating from 1st wife- drank gallons of alcohol passed out for 24
hrs- developed rhabdomyelosis hosp for 2 ICU then 1 wk APTU escaped from
aptu- went back was released took 100 xtra strength tylenol "felt better" was not
hospitalized
around 29 tried counseling mood was changing down all the time for reason
wing, griswold - was prescribed diffent medication "none worked"
Medication History: Depakote
ritalin
risperdal
currently on diclofenac
Key Testing/Lab
Results: CMP- wnl except sl elevated BUN 21
CBC wnl
VPA 55.5 on 500 BID
Review of Systems: "i have tendonitis all over- I hjave soft tisue damage all over the doctors cant
figure ot what it is they say its in my head"
r rotatocuff injury when hit- 3 surguries became imfected still not right
orthoscopic sugery on l wrist
fell and head last summer- passed out from pain-large scar on r temple states he
did not have concussion
r knee orthoscopis surgery r knee-
Other Systems
Reviewed and Negative: Yes
Medical Conditions: Does person served have any medical conditions that required consideration in
prescribing (i.e. pregnancy, diabetes, etc.)?
Yes
No
E &M Mental Status Exam
General Appearance/
Hygiene/Build: WNL
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 1 of 6 Date Printed: 3/26/2025 3:42 PM
Comments:
Eye Contact/Attention/
Concentration: WNL
Comments:
Gait/Station/Body
Movement: WNL
Comments:
Muscle Strength/Tone/
AIMS: WNL
Comments:
Behavior: WNL
Comments:
Speech/Language: WNL
Comments:
Self-Reported Mood: WNL
Comments: depressed
Emotional State-Affect: WNL
Comments:
Hallucinations: None Noted None Reported
Comments:
Delusions: None Noted None Reported
Comments: did not discuss
Thought Content: WNL
Comments: suicidal thoughts
Thought Process: WNL
Comments: racing
Associations: WNL
Comments:
Self-Injurious Thoughts: WNL
Comments:
Suicidal Thoughts: WNL
Comments: constant no intent or plan
Aggressive Thoughts: WNL
Comments:
Cognitive Functioning/
Fund of Knowledge: WNL Intellectual Disability Other, describe
Comments:
Orientation: WNL
Disoriented to: Person
Place
Situation Time
Comments:
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 2 of 6 Date Printed: 3/26/2025 3:42 PM
Memory: WNL
Comments:
Insight: WNL
Comments: fair
Judgment: WNL
Comments: poor
Impulsivity: None Noted None Reported
Comments:
Comments:
Vitals Entry
Date: 02/04/2015
02:30 PM
Unable to Collect:
Blood Pressure: Systolic
Diastolic
Heart Rate:
Respiration Rate:
Temperature: Fahrenheit
Source of Height/Weight: Gathered Directly
Height: Field accepts inches only - be sure to convert feet to inches
72
Weight: Pounds
212
BMI: 28.75
Pain Scale:
Client Medications
Begin Date End Date Amount/Refills Status
2/4/2015 (Not Set) 90/0 Active
Medication and Dosage: lithium carbonate (lithium carbonate) 300 mg capsule 3 capsule
Sig: 3 capsule by mouth as directed
2/4/2015 (Not Set) 60/0 Active
Medication and Dosage: olanzapine (olanzapine) 15 mg tablet 2 tablet
Sig: 2 tablet by mouth at bedtime
1/7/2015 2/4/2015 30/0 Inactive
Medication and Dosage: olanzapine (olanzapine) 15 mg tablet 1 tablet
Sig: 1 tablet by mouth at bedtime
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 3 of 6 Date Printed: 3/26/2025 3:42 PM
11/19/2014 (Not Set) 60/1 Active
Medication and Dosage: Depakote (divalproex) 500 mg tablet,delayed release (DR/EC) 1 tablet
Sig: 1 tablet by mouth twice a day
11/19/2014 (Not Set) 60/0 Active
Medication and Dosage: benztropine (benztropine) 1 mg tablet 1 tablet
Sig: Take 1 tablet by mouth every evening as needed
Client DSM Diagnosis as of 2/4/2015
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 2/4/2015
Diagnosis By: Sanders, Regina (002736)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1 r/o psychosis
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
301.9 - Personality Disorder
NOS 301.9 - PERSONALITY
DISORDER NOS 2 cluster b , predominant
borderline traits but also
antisocial, and narcissistic
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Severe
Problems with access to health care services Mild feels the doctors are not treating his muscle
pain
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 46
Impression/Plan
Impression: Not a danger to self or others at this time.Denies plan or intent to act on angry
feelings Mood d/o nos
Problems/Plans: (Include information about problem status, interventions)
mood- depressed suicidal thoughts continue depakote at 500mg BID ( did not
like hiher dose) start lithium titrate to 900mg get blood work lico3 vpa cmp lipids
wbc tsh
racing irritable continues increase Zyprexa to 30mg po QHS
reviewed crisis # in case of increased SI
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 4 of 6 Date Printed: 3/26/2025 3:42 PM
Reviewed Medications
With Person/Guardian: Explained rationale for medication choices, reviewed mixture of medications,
discussed possible risks, benefits, effectiveness (if applicable) and alternate
treatment with person/guardian?
Yes
No
Person: Understands
Information
Does Not Understand
Information
Agrees With Medication
Refuses Medication
Other
Guardian: Understands
Information
Does Not Understand
Information
Agrees With Medication
Refuses Medication
Other
Comments:
Psychotherapy
Delivered? No Yes
Return To Clinic In: 1 mo
Additional Services
Setting: Inpatient
Outpatient
SNF/ALF
Client Status: New Patient Existing Patient Consultation
Was >50% of time
used for
counseling:
Yes
No
Total
Psychotherapy
time (minutes):
Evaluation and Management Calculator
History Type Exam Type MDM Type
None None None
Problem Focused Problem Focused Straightforward
Expanded Problem
Focused Expanded Problem
Focused Low Complexity
Detailed Detailed Moderate Complexity
Comprehensive Comprehensive High Complexity
E/M Level: 3
Educational Materials
Were any educational
materials given to
person today?
Yes
No
Signatures
Signature #1: Regina Sanders (APRN/NP) - 2/4/2015 2:39 PM
Signature History
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 5 of 6 Date Printed: 3/26/2025 3:42 PM
Action Date Staff
Document Signed 2/4/2015 Regina Sanders (APRN/
NP)
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 6 of 6 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Sanders, Regina (002736)
Service Date/Time: 3/4/2015 1:40 PM
- 2:00 PM
Client Program: Medication Clinic (MED)
Activity: Evaluation & Management (E&M)
Payer: Tufts Health Together MCO(TuftsHT)
Procedure Code: 99213 : SA
Units: 1.00
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychiatry Note E&M
Persons Present: richard
Chief Complaint: I took 2 of the 20's until I got the 30mg - I feel better with the 30mg I had so
much anxiety
Interval HPI: Mood-improved some anxiety
thoughts- have stopped racing
appetite "I eat on schedule"
sleep - good, "I dont dream"
Pertinent Medical,
Social and Family
History:
reconciled with wife living in warren
divorced from 1st wife # children- no contact
was student at scc- has not worked recently does not have SSI
as a child I went to counseling- they thought I had ADHD- Im pretty sure I was on
ritalin- stopped in forth grade- I was awful in school- I threw water on the floor to
see kids fall down, I picked on people
2004- was separating from 1st wife- drank gallons of alcohol passed out for 24
hrs- developed rhabdomyelosis hosp for 2 ICU then 1 wk APTU escaped from
aptu- went back was released took 100 xtra strength tylenol "felt better" was not
hospitalized
around 29 tried counseling mood was changing down all the time for reason
wing, griswold - was prescribed diffent medication "none worked"
Medication History: Depakote
ritalin
risperdal
currently on diclofenac
Key Testing/Lab
Results: CMP- wnl except sl elevated BUN 21
CBC wnl
VPA 55.5 on 500 BID
Lithium level
Review of Systems: "i have tendonitis all over- I hjave soft tisue damage all over the doctors cant
figure ot what it is they say its in my head"
r rotatocuff injury when hit- 3 surguries became imfected still not right
orthoscopic sugery on l wrist
fell and head last summer- passed out from pain-large scar on r temple states he
did not have concussion
r knee orthoscopis surgery r knee-
Other Systems
Reviewed and Negative: Yes
Medical Conditions: Does person served have any medical conditions that required consideration in
prescribing (i.e. pregnancy, diabetes, etc.)?
Yes
No
E &M Mental Status Exam
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 1 of 6 Date Printed: 3/26/2025 3:42 PM
General Appearance/
Hygiene/Build: WNL
Comments:
Eye Contact/Attention/
Concentration: WNL
Comments: intense
Gait/Station/Body
Movement: WNL
Comments:
Muscle Strength/Tone/
AIMS: WNL
Comments:
Behavior: WNL
Comments:
Speech/Language: WNL
Comments:
Self-Reported Mood: WNL
Comments: anxious at times
Emotional State-Affect: WNL
Comments:
Hallucinations: None Noted None Reported
Comments:
Delusions: None Noted None Reported
Comments: stated hat he has moved out of springfield because of threats from the women
who hit him with her car-
Thought Content: WNL
Comments:
Thought Process: WNL
Comments: racing thoughts
Associations: WNL
Comments:
Self-Injurious Thoughts: WNL
Comments:
Suicidal Thoughts: WNL
Comments:
Aggressive Thoughts: WNL
Comments: have diminished
Cognitive Functioning/
Fund of Knowledge: WNL Intellectual Disability Other, describe
Comments:
Orientation: WNL
Disoriented to: Person Place Situation
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 2 of 6 Date Printed: 3/26/2025 3:42 PM
Time
Comments:
Memory: WNL
Comments:
Insight: WNL
Comments:
Judgment: WNL
Comments:
Impulsivity: None Noted None Reported
Comments:
Comments:
Vitals Entry
Date: 03/04/2015
01:39 PM
Unable to Collect:
Blood Pressure: Systolic
Diastolic
Heart Rate:
Respiration Rate:
Temperature: Fahrenheit
Source of Height/Weight: Gathered Directly
Height: Field accepts inches only - be sure to convert feet to inches
72
Weight: Pounds
212
BMI: 28.75
Pain Scale:
Client Medications
Begin Date End Date Amount/Refills Status
3/4/2015 (Not Set) 120/0 Active
Medication and Dosage: lithium carbonate (lithium carbonate) 300 mg capsule 4 capsule
Sig: Take 4 capsule by mouth at bedtime
2/4/2015 (Not Set) 60/0 Active
Medication and Dosage: olanzapine (olanzapine) 15 mg tablet 2 tablet
Sig: 2 tablet by mouth at bedtime
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 3 of 6 Date Printed: 3/26/2025 3:42 PM
2/4/2015 3/4/2015 90/0 Inactive
Medication and Dosage: lithium carbonate (lithium carbonate) 300 mg capsule 3 capsule
Sig: 3 capsule by mouth as directed
11/19/2014 (Not Set) 60/1 Active
Medication and Dosage: Depakote (divalproex) 500 mg tablet,delayed release (DR/EC) 1 tablet
Sig: 1 tablet by mouth twice a day
11/19/2014 (Not Set) 60/0 Active
Medication and Dosage: benztropine (benztropine) 1 mg tablet 1 tablet
Sig: Take 1 tablet by mouth every evening as needed
Client DSM Diagnosis as of 3/4/2015
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 3/4/2015
Diagnosis By: Sanders, Regina (002736)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code -
Description ICD-9 Code - Short
Description SNOMED Code -
Description Pri/Sec Comments
296.90 - Mood
Disorder NOS 296.90 - EPISODIC
MOOD DISORD NOS 1 r/o psychosis
Axis II: Personality Disorders and Mental Retardation
DSM Code -
Description ICD-9 Code - Short
Description SNOMED Code -
Description Pri/Sec Comments
301.9 - Personality
Disorder NOS 301.9 -
PERSONALITY
DISORDER NOS
2 cluster b ,
predominant
borderline traits but
also antisocial, and
narcissistic
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description SNOMED Code SNOMED
Description Pri/Sec
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Severe
Problems with access to health care services Mild feels the doctors are not treating his muscle
pain
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 46
Impression/Plan
Impression: Not a danger to self or others at this time.Denies plan or intent to act on angry
feelings Mood d/o nos
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 4 of 6 Date Printed: 3/26/2025 3:42 PM
Problems/Plans: (Include information about problem status, interventions)
mood- depressed suicidal thoughts continue depakote at 500mg BID ( did not
like higher dose) start lithium titrate to 900mg get blood work lico3 vpa cmp lipids
wbc tsh
racing irritable continues increase Zyprexa to 30mg po QHS
reviewed crisis # in case of increased SI
Reviewed Medications
With Person/Guardian: Explained rationale for medication choices, reviewed mixture of medications,
discussed possible risks, benefits, effectiveness (if applicable) and alternate
treatment with person/guardian?
Yes
No
Person: Understands
Information
Does Not Understand
Information
Agrees With Medication
Refuses Medication
Other
Guardian: Understands
Information
Does Not Understand
Information
Agrees With Medication
Refuses Medication
Other
Comments:
Psychotherapy
Delivered? No Yes
Return To Clinic In: 2 mos
Additional Services
Setting: Inpatient
Outpatient
SNF/ALF
Client Status: New Patient Existing Patient Consultation
Was >50% of time
used for
counseling:
Yes
No
Total
Psychotherapy
time (minutes):
Evaluation and Management Calculator
History Type Exam Type MDM Type
None None None
Problem Focused Problem Focused Straightforward
Expanded Problem
Focused Expanded Problem
Focused Low Complexity
Detailed Detailed Moderate Complexity
Comprehensive Comprehensive High Complexity
E/M Level: 3
Signatures
Signature #1: Regina Sanders (APRN/NP) - 4/8/2015 11:20 PM
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 5 of 6 Date Printed: 3/26/2025 3:42 PM
Signature History
Action Date Staff
Document Signed 4/8/2015 Regina Sanders (APRN/
NP)
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 6 of 6 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Sanders, Regina (002736)
Service Date/Time: 4/2/2015 12:30 PM
- 1:00 PM
Client Program: Medication Clinic (MED)
Activity: Evaluation & Management (E&M)
Payer: Tufts Health Together MCO(TuftsHT)
Procedure Code: 99213 : SA
Units: 1.00
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychiatry Note E&M
Persons Present: richard
Chief Complaint: I feel good-do any of my meds cause a reduced sperm count??
Interval HPI: Mood-improved some anxiety
thoughts- have stopped racing
appetite "I eat on schedule"
sleep - good, "I dont dream"
Pertinent Medical,
Social and Family
History:
reconciled with wife living in warren
divorced from 1st wife # children- no contact
was student at scc- has not worked recently does not have SSI
as a child I went to counseling- they thought I had ADHD- Im pretty sure I was on
ritalin- stopped in forth grade- I was awful in school- I threw water on the floor to
see kids fall down, I picked on people
2004- was separating from 1st wife- drank gallons of alcohol passed out for 24
hrs- developed rhabdomyelosis hosp for 2 ICU then 1 wk APTU escaped from
aptu- went back was released took 100 xtra strength tylenol "felt better" was not
hospitalized
around 29 tried counseling mood was changing down all the time for reason
wing, griswold - was prescribed diffent medication "none worked"
Medication History: Depakote
ritalin
risperdal
currently on diclofenac
Key Testing/Lab
Results: CMP- wnl except sl elevated BUN 21
CBC wnl
VPA 55.5 on 500 BID
Lithium level
Review of Systems: "i have tendonitis all over- I hjave soft tisue damage all over the doctors cant
figure ot what it is they say its in my head"
r rotatocuff injury when hit- 3 surguries became imfected still not right
orthoscopic sugery on l wrist
fell and head last summer- passed out from pain-large scar on r temple states he
did not have concussion
r knee orthoscopis surgery r knee-
Other Systems
Reviewed and Negative: Yes
Medical Conditions: Does person served have any medical conditions that required consideration in
prescribing (i.e. pregnancy, diabetes, etc.)?
Yes
No
E &M Mental Status Exam
General Appearance/ WNL
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 1 of 6 Date Printed: 3/26/2025 3:42 PM
Hygiene/Build:
Comments:
Eye Contact/Attention/
Concentration: WNL
Comments:
Gait/Station/Body
Movement: WNL
Comments:
Muscle Strength/Tone/
AIMS: WNL
Comments:
Behavior: WNL
Comments:
Speech/Language: WNL
Comments:
Self-Reported Mood: WNL
Comments:
Emotional State-Affect: WNL
Comments:
Hallucinations: None Noted None Reported
Comments:
Delusions: None Noted None Reported
Comments:
Thought Content: WNL
Comments:
Thought Process: WNL
Comments:
Associations: WNL
Comments:
Self-Injurious Thoughts: WNL
Comments:
Suicidal Thoughts: WNL
Comments:
Aggressive Thoughts: WNL
Comments:
Cognitive Functioning/
Fund of Knowledge: WNL Intellectual Disability Other, describe
Comments:
Orientation: WNL
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 2 of 6 Date Printed: 3/26/2025 3:42 PM
Disoriented to: Person
Place
Situation Time
Comments:
Memory: WNL
Comments:
Insight: WNL
Comments:
Judgment: WNL
Comments:
Impulsivity: None Noted None Reported
Comments:
Comments:
Vitals Entry
Date: 04/14/2015
02:04 AM
Unable to Collect:
Blood Pressure: Systolic
Diastolic
Heart Rate:
Respiration Rate:
Temperature: Fahrenheit
Source of Height/Weight: Gathered Directly
Height: Field accepts inches only - be sure to convert feet to inches
72
Weight: Pounds
212
BMI: 28.75
Pain Scale:
Client Medications
Begin Date End Date Amount/Refills Status
3/4/2015 (Not Set) 120/0 Active
Medication and Dosage: lithium carbonate (lithium carbonate) 300 mg capsule 4 capsule
Sig: Take 4 capsule by mouth at bedtime
2/4/2015 (Not Set) 60/0 Active
Medication and Dosage: olanzapine (olanzapine) 15 mg tablet 2 tablet
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 3 of 6 Date Printed: 3/26/2025 3:42 PM
Sig: 2 tablet by mouth at bedtime
11/19/2014 (Not Set) 60/1 Active
Medication and Dosage: Depakote (divalproex) 500 mg tablet,delayed release (DR/EC) 1 tablet
Sig: 1 tablet by mouth twice a day
11/19/2014 (Not Set) 60/0 Active
Medication and Dosage: benztropine (benztropine) 1 mg tablet 1 tablet
Sig: Take 1 tablet by mouth every evening as needed
Client DSM Diagnosis as of 4/2/2015
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 4/2/2015
Diagnosis By: Sanders, Regina (002736)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code -
Description ICD-9 Code - Short
Description SNOMED Code -
Description Pri/Sec Comments
296.90 - Mood
Disorder NOS 296.90 - EPISODIC
MOOD DISORD NOS 1 r/o psychosis
Axis II: Personality Disorders and Mental Retardation
DSM Code -
Description ICD-9 Code - Short
Description SNOMED Code -
Description Pri/Sec Comments
301.9 - Personality
Disorder NOS 301.9 -
PERSONALITY
DISORDER NOS
2 cluster b ,
predominant
borderline traits but
also antisocial, and
narcissistic
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description SNOMED Code SNOMED
Description Pri/Sec
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Severe
Problems with access to health care services Mild feels the doctors are not treating his muscle
pain
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 46
Impression/Plan
Impression: Not a danger to self or others at this time.Denies plan or intent to act on angry
feelings Mood d/o nos
Problems/Plans: (Include information about problem status, interventions)
mood- stable cont Depakote & lithium
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 4 of 6 Date Printed: 3/26/2025 3:42 PM
psychosis/ rage cont Zyprexa to 30mg po QHS cogentin
reviewed all meds - Depakote may cause sexual dysfunction- pt agreed to wait
until next prescriber as I am leaving and want to limit major med changes in
interim
also questioned changing to BHN acquired clinic near home = msg left for clinics
vp
Reviewed Medications
With Person/Guardian: Explained rationale for medication choices, reviewed mixture of medications,
discussed possible risks, benefits, effectiveness (if applicable) and alternate
treatment with person/guardian?
Yes
No
Person: Understands
Information
Does Not Understand
Information
Agrees With Medication
Refuses Medication
Other
Guardian: Understands
Information
Does Not Understand
Information
Agrees With Medication
Refuses Medication
Other
Comments:
Psychotherapy
Delivered? No Yes
Return To Clinic In: 2 mos
Additional Services
Setting: Inpatient
Outpatient
SNF/ALF
Client Status: New Patient Existing Patient Consultation
Was >50% of time
used for
counseling:
Yes
No
Total
Psychotherapy
time (minutes):
Evaluation and Management Calculator
History Type Exam Type MDM Type
None None None
Problem Focused Problem Focused Straightforward
Expanded Problem
Focused Expanded Problem
Focused Low Complexity
Detailed Detailed Moderate Complexity
Comprehensive Comprehensive High Complexity
E/M Level: 3
Signatures
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 5 of 6 Date Printed: 3/26/2025 3:42 PM
Signature #1: Regina Sanders (APRN/NP) - 4/14/2015 2:08 AM
Signature History
Action Date Staff
Document Signed 4/14/2015 Regina Sanders (APRN/
NP)
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 6 of 6 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Sivak, Joseph (900354)
Service Date/Time: 6/2/2015 9:00 AM
- 9:40 AM
Client Program: Medication Clinic (MED)
Activity: Evaluation & Management (E&M)
Payer: Tufts Health Together MCO(TuftsHT)
Procedure Code: 99215 : U6
Units: 1.00
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychiatry Note E&M
Persons Present: Dr. and patient
Chief Complaint: I think the Depakote made me more anxious when I started I think the Depakote
may be reducing my sperm count
Interval HPI: Patient is very obsessive about his sperm count he's actually bought a
microscope and he and his wife look at it underneath the microscope and they
don't see any sperm. Patient is suicidal almost every day has no active plan and
he's not actively suicidal spend this way for years he had a couple of attempts
years ago he thinks of his family now and this stops him from killing himself.
Patient is not homicidal patient lives with his wife
patient had a vasectomy and 04 he does not want children
patient states he's been married three or four years he has three previous
children he is a strange from them he doesn't have to pay child support they are
with a different woman. Again patient is not want children he had avast ectomy
patient states when he married his current wife she said she didn't care about
having children or didn't want them but now that is changed patient feels
tremendous pressure to have children he is generally in denial of all this intends
to focus on the meds is giving him sexual side effects or he gets an erection and
then it goes away and then it comes back and also that it's reducing his sperm
count patient is not full-blown delusional on this but is profoundly anxious about
this.
Patient states that he doesn't think the meds are doing much of anything he
sleeping 8 to 10 hours he states he gets suicidal but before that his heart is
pounding his he has anxiety and before that he starts to obsess about things.
Patient generally obsesses and worries about the fact that he had a car accident
three or four years ago he was walking in a parking lot in a girl without insurance
backed up and hit him and somehow he punched his elbow through the
windshield the police charged him with malicious attacking of a vehicle patient
has no clear insight as to what the real clear events were but he's feeling
completely victimized by this he goes back to court and he has court now delayed
till September he's trying to get this removed from his record. Patient states he
needs to get her remove city can get a job he's at various job staying a year to
generally quits her leaves can really hold work states in high school used to get
straight F's and then at the end of the term of the semester he would work really
hard and get all a so he can end up with the sea for the class he used to like to
play practical jokes he denies psychotic symptoms believes he was on Ritalin as
a child
Pertinent Medical,
Social and Family
History:
reconciled with wife living in warren
divorced from 1st wife # children- no contact
was student at scc- has not worked recently does not have SSI
as a child I went to counseling- they thought I had ADHD- Im pretty sure I was on
ritalin- stopped in forth grade- I was awful in school- I threw water on the floor to
see kids fall down, I picked on people
2004- was separating from 1st wife- drank gallons of alcohol passed out for 24
hrs- developed rhabdomyelosis hosp for 2 ICU then 1 wk APTU escaped from
aptu- went back was released took 100 xtra strength tylenol "felt better" was not
hospitalized
around 29 tried counseling mood was changing down all the time for reason
wing, griswold - was prescribed diffent medication "none worked"
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 1 of 7 Date Printed: 3/26/2025 3:42 PM
Medication History: Depakote
ritalin
risperdal
currently on diclofenac
Key Testing/Lab
Results: Adjusting meds will be rechecking labs in the next couple of months not that
creatinine previously was 1.3 and lithium was 1.0
patient might have had some previous kidney problems after he overdosed ten to
12 years ago
Review of Systems: "i have tendonitis all over- I hjave soft tisue damage all over the doctors cant
figure ot what it is they say its in my head"
r rotatocuff injury when hit- 3 surguries became imfected still not right
orthoscopic sugery on l wrist
fell and head last summer- passed out from pain-large scar on r temple states he
did not have concussion
r knee orthoscopis surgery r knee-
Other Systems
Reviewed and Negative: Yes
Medical Conditions: Does person served have any medical conditions that required consideration in
prescribing (i.e. pregnancy, diabetes, etc.)?
Yes
No
E &M Mental Status Exam
General Appearance/
Hygiene/Build: WNL
Comments: Appears anxious
Eye Contact/Attention/
Concentration: WNL
Comments: Good eye contact
Gait/Station/Body
Movement: WNL
Comments: Normal limits
Muscle Strength/Tone/
AIMS: WNL
Comments: Well-developed well-nourished
Behavior: WNL
Comments: Anxious states nothing helps insists the meds don't do anything
Speech/Language: WNL
Comments: rapid rate
Self-Reported Mood: WNL
Comments: Mood is anxious all the time suicidal all the time
Emotional State-Affect: WNL
Comments: Affect is anxious and ruminative
Hallucinations: None Noted None Reported
Comments:
Delusions: None Noted None Reported
Comments: Very obsessive not quite delusional regarding his sperm count in the pressure
he's under arm to have a child even though he does not want any
Thought Content: WNL
Comments: As above there is no active suicidal ideation there is no active homicidal ideation
though clear-cut delusional patient gets anxious and ruminative about his court
case then he gets chest pain cozies anxious in his heart is racing and then he
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 2 of 7 Date Printed: 3/26/2025 3:42 PM
gets suicidal no active plans stinks of his family that stops him
Thought Process: WNL
Comments: There is ruminative circular perseverative thinking there is no loosening of
associations there is no blocking there is circumstantiality patient is not tangential
Associations: WNL
Comments: As above
Self-Injurious Thoughts: WNL
Comments:
Suicidal Thoughts: WNL
Comments: No active or imminent plans contracts for safety
Aggressive Thoughts: WNL
Comments:
Cognitive Functioning/
Fund of Knowledge: WNL Intellectual Disability Other, describe
Comments: Grossly intact by diagnostic interview cognitively
Orientation: WNL
Disoriented to: Person
Place
Situation Time
Comments:
Memory: WNL
Comments:
Insight: WNL
Comments: Insight none
Judgment: WNL
Comments: Judgment fair to minimal
Impulsivity: None Noted None Reported
Comments:
Comments:
Vitals Entry
Date: 06/02/2015
10:02 AM
Unable to Collect: Other
Blood Pressure: Systolic
Diastolic
Heart Rate:
Respiration Rate:
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 3 of 7 Date Printed: 3/26/2025 3:42 PM
Temperature: Fahrenheit
Source of Height/Weight: Gathered Directly
Height: Field accepts inches only - be sure to convert feet to inches
72
Weight: Pounds
212
BMI: 28.75
Pain Scale:
Client Medications
Begin Date End Date Amount/Refills Status
6/2/2015 (Not Set) 120/1 Active
Medication and Dosage: lithium carbonate (lithium carbonate) 300 mg capsule 2 capsule
Sig: Take 2 capsule by mouth twice a day
6/2/2015 (Not Set) 60/1 Active
Medication and Dosage: olanzapine (olanzapine) 20 mg tablet 1 tablet
Sig: Take 1 tablet twice a day
6/2/2015 (Not Set) 30/1 Active
Medication and Dosage: Zoloft (sertraline) 25 mg tablet 1 tablet
Sig: Take 1 tablet by mouth every morning
3/4/2015 6/2/2015 120/0 Inactive
Medication and Dosage: lithium carbonate (lithium carbonate) 300 mg capsule 4 capsule
Sig: Take 4 capsule by mouth at bedtime
2/4/2015 6/2/2015 60/0 Inactive
Medication and Dosage: olanzapine (olanzapine) 15 mg tablet 2 tablet
Sig: 2 tablet by mouth at bedtime
11/19/2014 6/2/2015 60/1 Inactive
Medication and Dosage: Depakote (divalproex) 500 mg tablet,delayed release (DR/EC) 1 tablet
Sig: 1 tablet by mouth twice a day
11/19/2014 6/2/2015 60/0 Inactive
Medication and Dosage: benztropine (benztropine) 1 mg tablet 1 tablet
Sig: Take 1 tablet by mouth every evening as needed
Client DSM Diagnosis as of 6/2/2015
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 6/2/2015
Diagnosis By: Sivak, Joseph (900354)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code -
Description ICD-9 Code - Short
Description SNOMED Code -
Description Pri/Sec Comments
296.90 - Mood
Disorder NOS 296.90 - EPISODIC
MOOD DISORD NOS 1 r/o psychosis
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 4 of 7 Date Printed: 3/26/2025 3:42 PM
Axis II: Personality Disorders and Mental Retardation
DSM Code -
Description ICD-9 Code - Short
Description SNOMED Code -
Description Pri/Sec Comments
301.9 - Personality
Disorder NOS 301.9 -
PERSONALITY
DISORDER NOS
2 cluster b ,
predominant
borderline traits but
also antisocial, and
narcissistic
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description SNOMED Code SNOMED
Description Pri/Sec
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Severe
Problems with access to health care services Mild feels the doctors are not treating his muscle
pain
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 46
Impression/Plan
Impression: Patient is extremely ruminative and obsessive he denies specific features of OCD
but his thinking is in this realm. Patient give some history of some manic type
features it's he has no insight into his illness and he somewhat of a vague
historian as he is so ruminative however he's obsessive about this accident and
there is a question of possibly some self-destructive behavior by accidents and
injuries he's at his also had a couple of suicide attempts and previously he's gone
for a month on an hour of sleep years ago his suicide attempts were years ago
he's chronically suicidal no active plans typically starts with rumination used to
have more anger now it's anxiety leading to a chest discomfort and racing heart
which leads to the suicidal thinking there is racing thoughts he complains of
which are consistent with bipolar but also ruminative thoughts which are very
obsessive.
Problems/Plans: (Include information about problem status, interventions)
1. Contracts for safety no need for hospitalization can stay safe
2. has a medical marijuana card states it doesn't help stop using marijuana
patient agrees
3. Stop using alcohol patient is drinking about once or twice a month patient
agrees to stop
4. Needs a psychotherapist recommend a male therapist at this time unclear
right patient wasn't set with another one or referred spoke with Melissa the
medical assistant who will send for referral to try to get this patient was
psychotherapy med management is improper and I will be of very little utility
without good ongoing psychotherapy for this patient certainly patient needs to
work on issues of the pressure he's up against a have children as well as thought
stopping in the rumination that he does leading to his anxiety to suicidality
5. increase Zyprexa he's been on 30 at bedtime will go to 40 and will do Zyprexa
20 mg BID to cover and compensate for the change of going off the depakote
6. d/c Depakote patient hates it believes it six acting as our believes when he
started his made his anxiety worse he states that was planned with Regina
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 5 of 7 Date Printed: 3/26/2025 3:42 PM
Richards to work off of this it's unlikely it's affecting his sperm are is erectile
dysfunction what is a bit risky leave this could lead to more manic behavior will
adjust the other medications
7. Change lithium to 600 mg B this may give better benefit of the over the course
of the day instead of 1200 at night, reviewed this patient
8. Discontinue cogentin patient states the olanazpine never really gave him side
effects he believes when he started the Depakote it was making him more
anxious
9. Start Zoloft 25 mg PO Q a.m. explained target side effects discussed the
sexual side effect issue in depth with patient again believe this is multifactorial
patient needs to work on this in depth in psychotherapy. This will be for the
ruminative obsessive anxiety and thinking again increase in the zyprexa and
balancing out the lithium will hopefully cover for any manic episodes we have
discontinued the Depakote but patient should have a reasonable coverage with
the increase in zyprexa and the changing of the lithium schedule
10. rtc 3 weeks
Reviewed Medications
With Person/Guardian:
Explained rationale for medication choices, reviewed mixture of medications,
discussed possible risks, benefits, effectiveness (if applicable) and alternate
treatment with person/guardian?
Yes
No
Person: Understands
Information
Does Not Understand
Information
Agrees With Medication
Refuses Medication
Other
Guardian: Understands
Information
Does Not Understand
Information
Agrees With Medication
Refuses Medication
Other
Comments:
Psychotherapy
Delivered? No Yes
Return To Clinic In: 3 weeks
Additional Services
Setting: Inpatient
Outpatient
SNF/ALF
Client Status: New Patient Existing Patient Consultation
Was >50% of time
used for
counseling:
Yes
No
Total
Psychotherapy
time (minutes):
Evaluation and Management Calculator
History Type Exam Type MDM Type
None None None
Problem Focused Problem Focused Straightforward
Expanded Problem Expanded Problem Low Complexity
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 6 of 7 Date Printed: 3/26/2025 3:42 PM
Focused Focused
Detailed Detailed Moderate Complexity
Comprehensive Comprehensive High Complexity
E/M Level: 5
Signatures
Signature #1: Joseph Sivak (MD/DO) - 6/2/2015 10:14 AM
Signature History
Action Date Staff
Document Signed 6/2/2015 Joseph Sivak (MD/DO)
Addenda
Narrative Signed By
Note carded and side effects of medications
were discussed and processed in depth with
patient patient understood the risks benefits
of meds as well as the target side effects we
had a long discussion about mania
hypomania and obsessive features patient
will monitor closely for meaning hypomania
we also discussed in depth throughout the
session the sexual side effects in patient
understood the medication the rationale for
medication and our target symptoms which
are suicidal ideation and suicidality almost
daily anxiety racing thoughts and ruminative
obsessive thinking as well as frustration and
irritability and feeling helpless. Patient agreed
with the medication choices
Joseph Sivak (MD/DO) - 6/2/2015 11:01 AM
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 7 of 7 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Sivak, Joseph (900354)
Service Date/Time: 6/24/2015 10:00 AM
- 10:30 AM
Client Program: Medication Clinic (MED)
Activity: Evaluation & Management (E&M)
Payer: Tufts Health Together MCO(TuftsHT)
Procedure Code: 99215 : U6
Units: 1.00
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychiatry Note E&M
Persons Present: doctor and patient
Chief Complaint: no changes still anxious and someitmes suicidal but I pace and that helps, no IP
or respite or crisis or ER sinc elast visit
Interval HPI: remains obsessive and ruminative, no therpay yet.
no benefit with zoloft no worsening sleeping well at night anxious all day, no
worse of depakote, tolerating meds thinks about suicide daily no active plans,
tried to get ajob as an MA thought that would help but did not get job,
Pertinent Medical,
Social and Family
History:
reconciled with wife living in warren
divorced from 1st wife # children- no contact
was student at scc- has not worked recently does not have SSI
as a child I went to counseling- they thought I had ADHD- Im pretty sure I was on
ritalin- stopped in forth grade- I was awful in school- I threw water on the floor to
see kids fall down, I picked on people
2004- was separating from 1st wife- drank gallons of alcohol passed out for 24
hrs- developed rhabdomyelosis hosp for 2 ICU then 1 wk APTU escaped from
aptu- went back was released took 100 xtra strength tylenol "felt better" was not
hospitalized
around 29 tried counseling mood was changing down all the time for reason
wing, griswold - was prescribed diffent medication "none worked"
Medication History: Depakote
ritalin
risperdal
currently on diclofenac
Key Testing/Lab
Results: Adjusting meds will be rechecking labs in the next couple of months not that
creatinine previously was 1.3 and lithium was 1.0
patient might have had some previous kidney problems after he overdosed ten to
12 years ago
june 24 , 2015- pt given lab slip today for lith level cmp fbs t4 tsh
Review of Systems: no changes
Other Systems
Reviewed and Negative: Yes
Medical Conditions: Does person served have any medical conditions that required consideration in
prescribing (i.e. pregnancy, diabetes, etc.)?
Yes
No
E &M Mental Status Exam
General Appearance/
Hygiene/Build: WNL
Comments: Anxious
Eye Contact/Attention/
Concentration: WNL
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 1 of 6 Date Printed: 3/26/2025 3:42 PM
Comments:
Gait/Station/Body
Movement: WNL
Comments:
Muscle Strength/Tone/
AIMS: WNL
Comments:
Behavior: WNL
Comments: Anxious five expansive detached but not hostile tested engaging still fairly
personable
Speech/Language: WNL
Comments: rapid and stacatto
Self-Reported Mood: WNL
Comments: Anxious
Emotional State-Affect: WNL
Comments: Anxious to accelerated slightly
Hallucinations: None Noted None Reported
Comments:
Delusions: None Noted None Reported
Comments: Obsessive rumination
Thought Content: WNL
Comments: No active suicidal or homicidal ideation no delusional Conta very obsessive room
and ruminative about the killing himself thinks about his family on he is not
showing him depression but more of an obsessive fixation
Thought Process: WNL
Comments: Circumstantial rapid
Associations: WNL
Comments: Rapid at points as above
Self-Injurious Thoughts: WNL
Comments:
Suicidal Thoughts: WNL
Comments: As above patient contracts for safety
Aggressive Thoughts: WNL
Comments:
Cognitive Functioning/
Fund of Knowledge: WNL Intellectual Disability Other, describe
Comments: Grossly intact
Orientation: WNL
Disoriented to: Person
Place
Situation Time
Comments:
Memory: WNL
Comments:
Insight: WNL
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 2 of 6 Date Printed: 3/26/2025 3:42 PM
Comments: None
Judgment: WNL
Comments: Fair
Impulsivity: None Noted None Reported
Comments: As above
Comments:
Vitals Entry
Date: 06/24/2015
10:31 AM
Unable to Collect: Other
Blood Pressure: Systolic
Diastolic
Heart Rate:
Respiration Rate:
Temperature: Fahrenheit
Source of Height/Weight: Gathered Directly
Height: Field accepts inches only - be sure to convert feet to inches
72
Weight: Pounds
212
BMI: 28.75
Pain Scale:
Client Medications
Begin Date End Date Amount/Refills Status
6/24/2015 (Not Set) 30/1 Active
Medication and Dosage: Zoloft (sertraline) 50 mg tablet 1 tablet
Sig: Take 1 tablet by mouth every morning
6/2/2015 (Not Set) 120/1 Active
Medication and Dosage: lithium carbonate (lithium carbonate) 300 mg capsule 2 capsule
Sig: Take 2 capsule by mouth twice a day
6/2/2015 (Not Set) 60/1 Active
Medication and Dosage: olanzapine (olanzapine) 20 mg tablet 1 tablet
Sig: Take 1 tablet twice a day
6/2/2015 6/24/2015 30/1 Inactive
Medication and Dosage: Zoloft (sertraline) 25 mg tablet 1 tablet
Sig: Take 1 tablet by mouth every morning
Client DSM Diagnosis as of 6/24/2015
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 3 of 6 Date Printed: 3/26/2025 3:42 PM
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 6/24/2015
Diagnosis By: Sivak, Joseph (900354)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code -
Description ICD-9 Code - Short
Description SNOMED Code -
Description Pri/Sec Comments
296.90 - Mood
Disorder NOS 296.90 - EPISODIC
MOOD DISORD NOS 1 r/o psychosis
Axis II: Personality Disorders and Mental Retardation
DSM Code -
Description ICD-9 Code - Short
Description SNOMED Code -
Description Pri/Sec Comments
301.9 - Personality
Disorder NOS 301.9 -
PERSONALITY
DISORDER NOS
2 cluster b ,
predominant
borderline traits but
also antisocial, and
narcissistic
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description SNOMED Code SNOMED
Description Pri/Sec
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Severe
Problems with access to health care services Mild feels the doctors are not treating his muscle
pain
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 46
Impression/Plan
Impression: Patient is extremely ruminative and obsessive he denies specific features of OCD
but his thinking is in this realm. Patient give some history of some manic type
features it's he has no insight into his illness and he somewhat of a vague
historian as he is so ruminative however he's obsessive about this accident and
there is a question of possibly some self-destructive behavior by accidents and
injuries he's at his also had a couple of suicide attempts and previously he's gone
for a month on an hour of sleep years ago his suicide attempts were years ago
he's chronically suicidal no active plans typically starts with rumination used to
have more anger now it's anxiety leading to a chest discomfort and racing heart
which leads to the suicidal thinking there is racing thoughts he complains of
which are consistent with bipolar but also ruminative thoughts which are very
obsessive.
Today June 24 there are no major changes he really he remains obsessive and
ruminative he is sleeping well at night he does appear expansive at the
appointment but essentially unchanged from previous there is no benefit or side
effect or any clear mood cycling or any increase in suicidality with the Zoloft
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 4 of 6 Date Printed: 3/26/2025 3:42 PM
however there is no decrease in there is no improvement in the obsessive
rumination
patient states he is stopped marijuana and alcohol
Problems/Plans: (Include information about problem status, interventions)
1. Contracts for safety no need for hospitalization can stay safe at this time
2. has a medical marijuana card states it doesn't help stop using marijuana
patient agrees as of June 24, 2015 patient states he has stopped completely
3. Stop using alcohol patient is drinking about once or twice a month patient
agrees to stop as of June 24, 2015 patient states he has stopped alcohol
completely
4. NEEDS A PSYCHOTHERAPIST recommend a male therapist at this time
unclear right patient wasn't set with another one or referred spoke with Melissa
the medical assistant who will send for referral to try to get this patient was
psychotherapy med management is improper and I will be of very little utility
without good ongoing psychotherapy for this patient certainly patient needs to
work on issues of the pressure he's up against a have children as well as thought
stopping in the rumination that he does leading to his anxiety to suicidality
patient is not heard anything on a therapist yet did discuss this with Melissa MA
and she is working on getting patient a psychotherapist he agrees to go
5. continue Zyprexa Zyprexa 20 mg BID to cover and compensate for the
change of going off the depakote
6. Continue lithium to 600 mg BID
7. increase Zoloft to 50 mg PO Q a.m. explained target side effects discussed
the sexual side effect issue in depth with patient again believe this is multifactorial
patient needs to work on this in depth in psychotherapy. This will be for
rumination and obsessiveness, monitor for any increase in hypomania closely
8. LABS check lithium cmp fbs t4 tsh
9. rtc 3 weeks contracts clearly for safety
Reviewed Medications
With Person/Guardian: Explained rationale for medication choices, reviewed mixture of medications,
discussed possible risks, benefits, effectiveness (if applicable) and alternate
treatment with person/guardian?
Yes
No
Person: Understands
Information
Does Not Understand
Information
Agrees With Medication
Refuses Medication
Other
Guardian: Understands
Information
Does Not Understand
Information
Agrees With Medication
Refuses Medication
Other
Comments:
Psychotherapy
Delivered? No Yes
Return To Clinic In: 3 weeks
Additional Services
Setting: Inpatient
Outpatient
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 5 of 6 Date Printed: 3/26/2025 3:42 PM
SNF/ALF
Client Status: New Patient Existing Patient Consultation
Was >50% of time
used for
counseling:
Yes
No
Total
Psychotherapy
time (minutes):
Evaluation and Management Calculator
History Type Exam Type MDM Type
None None None
Problem Focused Problem Focused Straightforward
Expanded Problem
Focused Expanded Problem
Focused Low Complexity
Detailed Detailed Moderate Complexity
Comprehensive Comprehensive High Complexity
E/M Level: 5
Signatures
Signature #1: Joseph Sivak (MD/DO) - 6/24/2015 10:38 AM
Signature History
Action Date Staff
Document Signed 6/24/2015 Joseph Sivak (MD/DO)
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 6 of 6 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Sivak, Joseph (900354)
Service Date/Time: 7/15/2015 11:30 AM
- 12:00 PM
Client Program: Medication Clinic (MED)
Activity: Evaluation & Management (E&M)
Payer: Tufts Health Together MCO(TuftsHT)
Procedure Code: 99214 : U6
Units: 1.00
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychiatry Note E&M
Persons Present: doctor and patient
Chief Complaint: multplle complaints pt has a list from wife, -
Interval HPI: multplle complaints pt has a list from wife, - no sex drive, pt passing out, light
headed low BP he feels, poor memor as notied by wife, an also pacing. pt
conitnue with chronic suicidality, but no active plans, is behaviorall on control
state he quit cannibas and etoh
Pertinent Medical,
Social and Family
History:
reconciled with wife living in warren
divorced from 1st wife # children- no contact
was student at scc- has not worked recently does not have SSI
as a child I went to counseling- they thought I had ADHD- Im pretty sure I was on
ritalin- stopped in forth grade- I was awful in school- I threw water on the floor to
see kids fall down, I picked on people
2004- was separating from 1st wife- drank gallons of alcohol passed out for 24
hrs- developed rhabdomyelosis hosp for 2 ICU then 1 wk APTU escaped from
aptu- went back was released took 100 xtra strength tylenol "felt better" was not
hospitalized
around 29 tried counseling mood was changing down all the time for reason
wing, griswold - was prescribed diffent medication "none worked"
Medication History: Depakote
ritalin
risperdal
currently on diclofenac
Key Testing/Lab
Results: curren labs creatinine rmeians at 1.3 lithium level is .9
thyroids renal and liver wnl fro 6/30/15
Review of Systems: no changes as above complaints
Other Systems
Reviewed and Negative:
Yes
Medical Conditions: Does person served have any medical conditions that required consideration in
prescribing (i.e. pregnancy, diabetes, etc.)?
Yes
No
E &M Mental Status Exam
General Appearance/
Hygiene/Build: WNL
Comments: dd wearing sunglasses some psychomotr agitation
Eye Contact/Attention/
Concentration: WNL
Comments: fair wearig dark glases
Gait/Station/Body
Movement: WNL
Comments:
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 1 of 5 Date Printed: 3/26/2025 3:42 PM
Muscle Strength/Tone/
AIMS: WNL
Comments:
Behavior: WNL
Comments: odd detached
Speech/Language: WNL
Comments: slowed
Self-Reported Mood: WNL
Comments: not good
Emotional State-Affect: WNL
Comments: odd auomated constricted in this range
Hallucinations: None Noted None Reported
Comments: may be hallucinating
Delusions: None Noted None Reported
Comments:
Thought Content: WNL
Comments: as above see hpi
Thought Process: WNL
Comments: slowed some blocking possibly
Associations: WNL
Comments: slowed
Self-Injurious Thoughts: WNL
Comments:
Suicidal Thoughts: WNL
Comments: chornic no active plans
Aggressive Thoughts: WNL
Comments:
Cognitive Functioning/
Fund of Knowledge: WNL Intellectual Disability Other, describe
Comments:
Orientation: WNL
Disoriented to: Person
Place
Situation Time
Comments:
Memory: WNL
Comments:
Insight: WNL
Comments: none
Judgment: WNL
Comments: none
Impulsivity: None Noted None Reported
Comments:
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 2 of 5 Date Printed: 3/26/2025 3:42 PM
Comments:
Vitals Entry
Date: 07/15/2015
12:12 PM
Unable to Collect: Other
Blood Pressure: Systolic
Diastolic
Heart Rate:
Respiration Rate:
Temperature: Fahrenheit
Source of Height/Weight: Gathered Directly
Height: Field accepts inches only - be sure to convert feet to inches
72
Weight: Pounds
212
BMI: 28.75
Pain Scale:
Client Medications
Begin Date End Date Amount/Refills Status
6/24/2015 (Not Set) 30/1 Active
Medication and Dosage: Zoloft (sertraline) 50 mg tablet 1 tablet
Sig: Take 1 tablet by mouth every morning
6/2/2015 (Not Set) 120/1 Active
Medication and Dosage: lithium carbonate (lithium carbonate) 300 mg capsule 2 capsule
Sig: Take 2 capsule by mouth twice a day
6/2/2015 (Not Set) 60/1 Active
Medication and Dosage: olanzapine (olanzapine) 20 mg tablet 1 tablet
Sig: Take 1 tablet twice a day
Client DSM Diagnosis as of 7/15/2015
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 7/15/2015
Diagnosis By: Sivak, Joseph (900354)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code -
Description ICD-9 Code - Short
Description SNOMED Code -
Description Pri/Sec Comments
296.90 - Mood
Disorder NOS 296.90 - EPISODIC
MOOD DISORD NOS 1 r/o psychosis
Axis II: Personality Disorders and Mental Retardation
DSM Code -
Description ICD-9 Code - Short
Description SNOMED Code -
Description Pri/Sec Comments
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 3 of 5 Date Printed: 3/26/2025 3:42 PM
301.9 - Personality
Disorder NOS 301.9 -
PERSONALITY
DISORDER NOS
2 cluster b ,
predominant
borderline traits but
also antisocial, and
narcissistic
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description SNOMED Code SNOMED
Description Pri/Sec
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Severe
Problems with access to health care services Mild feels the doctors are not treating his muscle
pain
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 46
Impression/Plan
Impression: pt comtinues with odd presentation suspect while no overt amissio n of
hallucinations and no overt odd fixed dleusional that pt may be more in
schizohrenic or schizoafective realm, oerall psychiatrically pt is in control,
Problems/Plans: (Include information about problem status, interventions)
1. Contracts for safety no need for hospitalization can stay safe at this time
2. no MJ or ETOH pt claims to have stopped
3. will lower zyprexa to 10 mg qam and 20 mg qhs as pt is lightheaded and passs
out and memory disturbance etc
4. NEEDS A PSYCHOTHERAPIST Mlissa the MA advised pt will be geting
shcheduled soon with Leslie a therapist
5. Continue lithium to 600 mg BID with increased creatinine and odd and
multiple SE as noted above, if no improvement with decrease in zyprexa will
consider decrease in lithium at next appt.
7. continue Zoloft to 50 mg PO Q a.m. pt insists Se he complns about have
bene there longer than zoloft and zoloft at this poitn is not making things better or
worse from what he can tell.
8. RTC one month- contracts for safety
9. get a primary care appt with Dr Skalski at Riverbend ASAP pt agrees he can
and will do this to check on "passing out"
10. note pt on Clomid he states from a urologist for past month. apparently for
"spermatogenesis", pt not sure if any of te SE could be rleated to this. pt to see
primary care
Reviewed Medications
With Person/Guardian: Explained rationale for medication choices, reviewed mixture of medications,
discussed possible risks, benefits, effectiveness (if applicable) and alternate
treatment with person/guardian?
Yes
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 4 of 5 Date Printed: 3/26/2025 3:42 PM
No
Person: Understands
Information
Does Not Understand
Information
Agrees With Medication
Refuses Medication
Other
Guardian: Understands
Information
Does Not Understand
Information
Agrees With Medication
Refuses Medication
Other
Comments:
Psychotherapy
Delivered? No Yes
Return To Clinic In:
Additional Services
Setting: Inpatient
Outpatient
SNF/ALF
Client Status: New Patient Existing Patient Consultation
Was >50% of time
used for
counseling:
Yes
No
Total
Psychotherapy
time (minutes):
Evaluation and Management Calculator
History Type Exam Type MDM Type
None None None
Problem Focused Problem Focused Straightforward
Expanded Problem
Focused Expanded Problem
Focused Low Complexity
Detailed Detailed Moderate Complexity
Comprehensive Comprehensive High Complexity
E/M Level: 4
Signatures
Signature #1: Joseph Sivak (MD/DO) - 7/15/2015 12:22 PM
Signature History
Action Date Staff
Document Signed 7/15/2015 Joseph Sivak (MD/DO)
Behavioral Health Network, Inc. -
Psychopharmocology Progress Note
Stebbins, Richard (110100) 5 of 5 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Andrews, Meghan (004365)
Service Date/Time: 6/25/2014 11:30 AM
- 12:30 PM
Client Program: Outpatient (OP)
Activity: Diagnostic (DIAG)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
New Issue(s) Presented
today: None Reported
New Issue resolved, no CA update required
CA Update Required
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect agitated
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Risk Assessment
Danger To: None
Check all that apply below and record action taken in
Therapeutic Interventions section
Danger To: Ideation Plan Intent Attempt Comments
Self denied plan/
intent
Others denied plan/
intent
Property
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Gathered information for intake and BPRS
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Plan/Additional
Information(Indicate
action plan between
sessions):
Goal(s) Addressed
No Goal(s) addressed were chosen
Goal(s) Addressed:
Client DSM Diagnosis as of 6/25/2014
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 6/25/2014
Diagnosis By: Andrews, Meghan (004365)
External Diagnosis? No
Description:
Diagnostic Formulation
Richard reported that since being hit by a car last year, he has experienced increasing anger and agitation. He
reported passive homicidal and suicidal thoughts, without a plan, means or intent to kill or harm anyone. Richard
reported that he has a short temper and becomes frustrated and aggravated by others very easily. He also reported
that he experiences daily anxiety with racing thoughts and rapid heart beat. Based on this information, the
diagnoses assigned include Mood Disorder NOS and Anxiety Disorder NOS.
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder 296.90 - EPISODIC MOOD 1
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
NOS DISORD NOS
300.00 - Anxiety Disorder
NOS 300.00 - ANXIETY STATE
NOS 2
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
799.9 - Diagnosis Deferred
on Axis II 799.9 - UNKN CAUSE
MORB/MORT NEC 2
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Mild
Problems with access to health care services Mild lack of outpatient mental health providers
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 50
Signatures
Signature #1: Meghan Andrews (Masters +2) - 6/25/2014 12:30 PM
Signature History
Action Date Staff
Document Signed 6/25/2014 Meghan Andrews
(Masters +2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 7/10/2014 3:30 PM
- 4:30 PM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Richard stated that he is about to have a snap and needs to be in medication
regime to calm himself.
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect irritable
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
gathered information and need assessment
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Richard was overtly complaint and expressed diasatisfaction and anger with the
doctors and police.
Plan/Additional
Information(Indicate
action plan between
sessions):
Need to calm hisself down through medication
Goal(s) Addressed
No Goal(s) addressed were chosen
Goal(s) Addressed: need assessment
Client DSM Diagnosis as of 7/10/2014
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 7/10/2014
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1
300.00 - Anxiety Disorder
NOS 300.00 - ANXIETY STATE
NOS 2
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
799.9 - Diagnosis Deferred
on Axis II 799.9 - UNKN CAUSE
MORB/MORT NEC 2
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Mild
Problems with access to health care services Mild lack of outpatient mental health providers
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 50
Signatures
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
Signature #1: Radha Adhikari (Masters +2) - 7/10/2014 4:37 PM
Signature History
Action Date Staff
Document Signed 7/10/2014 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 7/17/2014 9:00 AM
- 10:00 AM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Richard continues to report the anger building up on him against the legal system
he reports "the lawyers are helping the perpetrator get away". He stated that the
meds his PCP prescribed is not halping him calm down and his mind is racing all
along. However, he agreed that he attends gym everyday to keep fit.
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Supportive therapy, empathtic listening, encouragement for focusing on other
values of his life.
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Richard stated that he has to get the medication prescription from a psychiatrist
Plan/Additional
Information(Indicate
action plan between
sessions):
to provide respurces for calming himself down.
Goal(s) Addressed
No Goal(s) addressed were chosen
Goal(s) Addressed: thought reconstruction
Client DSM Diagnosis as of 7/17/2014
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 7/17/2014
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1
300.00 - Anxiety Disorder
NOS 300.00 - ANXIETY STATE
NOS 2
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
799.9 - Diagnosis Deferred
on Axis II 799.9 - UNKN CAUSE
MORB/MORT NEC 2
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Mild
Problems with access to health care services Mild lack of outpatient mental health providers
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 50
Signatures
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
Signature #1: Radha Adhikari (Masters +2) - 7/17/2014 10:08 AM
Signature History
Action Date Staff
Document Signed 7/17/2014 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 7/23/2014 1:00 PM
- 2:00 PM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Richard reported that everything is same and nothing has changed so far. he
reported that he feels the same way, frustrated and racing thioughts and nerver
been able to calm himself down. He reported that he worries about his problem
that does not seem to have "any recommendation for medical problems"
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Discussed on the treatment goal for the therapy sessions
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Richard is in agreement with the plan
Plan/Additional
Information(Indicate
action plan between
sessions):
to continue with weekly sessions
Goal(s) Addressed
No Goal(s) addressed were chosen
Goal(s) Addressed: Thought reconstruction
Client DSM Diagnosis as of 7/23/2014
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 7/23/2014
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1
300.00 - Anxiety Disorder
NOS 300.00 - ANXIETY STATE
NOS 2
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
799.9 - Diagnosis Deferred
on Axis II 799.9 - UNKN CAUSE
MORB/MORT NEC 2
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Mild
Problems with access to health care services Mild lack of outpatient mental health providers
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 50
Signatures
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
Signature #1: Radha Adhikari (Masters +2) - 7/23/2014 1:57 PM
Signature History
Action Date Staff
Document Signed 7/23/2014 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 8/6/2014 1:00 PM
- 1:53 PM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Richard continues to have racing thoughts and getting annoyed with situations
around him. he reports that being in Florida did not help either as the thoughts
about the injustice and the court as well as his felony charges follows him
everywhere. He continues to report thoughts of hurting people, however he
reports to the therapist that if acts on it, "it is not going to help either".
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Check all that apply below and record action taken in
Therapeutic Interventions section
Danger To: Ideation Plan Intent Attempt Comments
Self
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Others Reports
Passive HI
against law
enforcement
officials
Property
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Safety Assessment, Support and Encouragment towards the self care strategies.
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Client is responsive and states that he is hopeful that he gets medication for
calming down as early as possible
Plan/Additional
Information(Indicate
action plan between
sessions):
Richard will be coming in for sessions on biweekly basis and would like to review
when he starts seeing the psychiatrist.
Goal(s) Addressed
No Goal(s) addressed were chosen
Goal(s) Addressed: Safety assessment
Client DSM Diagnosis as of 8/6/2014
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 8/6/2014
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1
300.00 - Anxiety Disorder
NOS 300.00 - ANXIETY STATE
NOS 2
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
799.9 - Diagnosis Deferred
on Axis II 799.9 - UNKN CAUSE
MORB/MORT NEC 2
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
chronic pain 3
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Mild
Problems with access to health care services Mild lack of outpatient mental health providers
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 50
Signatures
Signature #1: Radha Adhikari (Masters +2) - 8/6/2014 2:11 PM
Signature History
Action Date Staff
Document Signed 8/6/2014 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 8/27/2014 9:00 AM
- 10:00 AM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Richard continue to report the racing thoughts and being "obsessed" by the court
and loath anyother people he meets at common places
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Supportive therapy, thought reconstruction, encouragement about the stress
management skills
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Richard requested for the records and is cooperative.
Plan/Additional
Information(Indicate
action plan between
sessions):
To continue assisitng him to work on truama symptoms
Goal(s) Addressed
No Goal(s) addressed were chosen
Goal(s) Addressed: CBT Skills
Client DSM Diagnosis as of 8/27/2014
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 8/27/2014
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1
300.00 - Anxiety Disorder
NOS 300.00 - ANXIETY STATE
NOS 2
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
799.9 - Diagnosis Deferred
on Axis II 799.9 - UNKN CAUSE
MORB/MORT NEC 2
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Mild
Problems with access to health care services Mild lack of outpatient mental health providers
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 50
Signatures
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
Signature #1: Radha Adhikari (Masters +2) - 8/27/2014 10:17 AM
Signature History
Action Date Staff
Document Signed 8/27/2014 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 9/3/2014 9:00 AM
- 10:00 AM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Richard reports that he continues to think about the court and canot get over it.
however he reported that the prescription from the doctor for marijuana clinic is
helpful for him short term for about two hours and then he feels the same way as
he used to before. he reported that he does not like to do it and requested to be
scheduled to see a Psychiatrist as early as possible.
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Explored the symptoms, feelings and thoughts with the new developments
medically and encouraged for the engaging in meaningful activities.
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Richard is in agreement and cooperative
Plan/Additional
Information(Indicate
action plan between
sessions):
To continue working on the trauma focused treatment plan
Goal(s) Addressed
IAP--Outpatient
Problem Mental Health/Illness Management
Goal Richard will decrease his anxiety syptoms
Objective Richard will be able to report less anxiety syptms and reduce by at least 90% .
Intervent-
ion Therapist will assist Richard to work on this thought reconstruction, stress management
skill, exploration of activities that keeps him engaged and decrease the thoughts of the
incidents and improve his health condition over all.
Problem Mental Health/Illness Management
Goal Person Served will establish chemical dependence recovery that leads to improved
physical and mental health.
Objective Person's served current signs and symptoms will be reduced through the
use of appropriate psychiatric medications.
Intervent-
ion Medication Education / Symptom / Illness Management
Goal(s) Addressed:
Client DSM Diagnosis as of 9/3/2014
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 9/3/2014
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1
300.00 - Anxiety Disorder
NOS 300.00 - ANXIETY STATE
NOS 2
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description
Pri/Sec Comments
799.9 - Diagnosis Deferred
on Axis II 799.9 - UNKN CAUSE
MORB/MORT NEC 2
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Mild
Problems with access to health care services Mild lack of outpatient mental health providers
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 50
Signatures
Signature #1: Radha Adhikari (Masters +2) - 9/3/2014 9:58 AM
Signature History
Action Date Staff
Document Signed 9/3/2014 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 9/17/2014 9:00 AM
- 10:00 AM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Richard reported that he continues feel anger bottled up inside, however he
thinks that his life will be better as he is moving out from the area with his wife.
He reported that the person who caused accident had a restraint order who
happened to live in few blocks from his regular place of residence
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Supportive therapy, demonstrated and practised meditation, anger managment
techniques.
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Richard was stated that he felt something is happening in his body and liked it
and would try the techniques
Plan/Additional
Information(Indicate
action plan between
sessions):
To continue working on stress managment and relaxation.
Goal(s) Addressed
IAP--Outpatient
Problem Mental Health/Illness Management
Goal Richard will decrease his anxiety syptoms
Objective Richard will be able to report less anxiety syptms and reduce by at least 90% .
Intervent-
ion Therapist will assist Richard to work on this thought reconstruction, stress management
skill, exploration of activities that keeps him engaged and decrease the thoughts of the
incidents and improve his health condition over all.
Problem Mental Health/Illness Management
Goal Person Served will establish chemical dependence recovery that leads to improved
physical and mental health.
Objective Person's served current signs and symptoms will be reduced through the
use of appropriate psychiatric medications.
Intervent-
ion Medication Education / Symptom / Illness Management
Goal(s) Addressed:
Client DSM Diagnosis as of 9/17/2014
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 9/17/2014
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1
300.00 - Anxiety Disorder
NOS 300.00 - ANXIETY STATE
NOS 2
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description
Pri/Sec Comments
799.9 - Diagnosis Deferred
on Axis II 799.9 - UNKN CAUSE
MORB/MORT NEC 2
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Mild
Problems with access to health care services Mild lack of outpatient mental health providers
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 50
Signatures
Signature #1: Radha Adhikari (Masters +2) - 9/17/2014 10:04 AM
Signature History
Action Date Staff
Document Signed 9/17/2014 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 9/29/2014 9:00 AM
- 10:00 AM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Richard reported that his week has been busy lately due to his move from the
area to Ware and he reported that "it gave me something to do besides thinking
about the court thing"
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Empathetic listening, supportive therapy, relaxation exercise and calming
techniques.
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Richard was agreeable
Plan/Additional
Information(Indicate
action plan between
sessions):
To continue working with him focused on thought reconstruction
Goal(s) Addressed
IAP--Outpatient
Problem Mental Health/Illness Management
Goal Richard will decrease his anxiety syptoms
Objective Richard will be able to report less anxiety syptms and reduce by at least 90% .
Intervent-
ion Therapist will assist Richard to work on this thought reconstruction, stress management
skill, exploration of activities that keeps him engaged and decrease the thoughts of the
incidents and improve his health condition over all.
Problem Mental Health/Illness Management
Goal Person Served will establish chemical dependence recovery that leads to improved
physical and mental health.
Objective Person's served current signs and symptoms will be reduced through the
use of appropriate psychiatric medications.
Intervent-
ion Medication Education / Symptom / Illness Management
Goal(s) Addressed:
Client DSM Diagnosis as of 9/29/2014
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 9/29/2014
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1
300.00 - Anxiety Disorder
NOS 300.00 - ANXIETY STATE
NOS 2
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description
Pri/Sec Comments
799.9 - Diagnosis Deferred
on Axis II 799.9 - UNKN CAUSE
MORB/MORT NEC 2
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Mild
Problems with access to health care services Mild lack of outpatient mental health providers
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 50
Signatures
Signature #1: Radha Adhikari (Masters +2) - 9/29/2014 12:11 PM
Signature History
Action Date Staff
Document Signed 9/29/2014 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 10/14/2014 2:00 PM
- 3:00 PM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Richard reported that he felt that the meditation seemed to be working but due to
the cough, he had to discontinue. he continues to report the racing thoughts and
not being able to focus.
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Empathetic listening, cognitive restructuring, activity scheduling and
encouragement for structured daily living situation
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Richard is agreeable
Plan/Additional
Information(Indicate
action plan between
sessions):
To continue in calming strategies
Goal(s) Addressed
IAP--Outpatient
Problem Mental Health/Illness Management
Goal Richard will decrease his anxiety syptoms
Objective Richard will be able to report less anxiety syptms and reduce by at least 90% .
Intervent-
ion Therapist will assist Richard to work on this thought reconstruction, stress management
skill, exploration of activities that keeps him engaged and decrease the thoughts of the
incidents and improve his health condition over all.
Problem Mental Health/Illness Management
Goal Person Served will establish chemical dependence recovery that leads to improved
physical and mental health.
Objective Person's served current signs and symptoms will be reduced through the
use of appropriate psychiatric medications.
Intervent-
ion Medication Education / Symptom / Illness Management
Goal(s) Addressed:
Client DSM Diagnosis as of 10/14/2014
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 10/14/2014
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1
300.00 - Anxiety Disorder
NOS 300.00 - ANXIETY STATE
NOS 2
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description
Pri/Sec Comments
799.9 - Diagnosis Deferred
on Axis II 799.9 - UNKN CAUSE
MORB/MORT NEC 2
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Mild
Problems with access to health care services Mild lack of outpatient mental health providers
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 50
Signatures
Signature #1: Radha Adhikari (Masters +2) - 10/15/2014 12:41 PM
Signature History
Action Date Staff
Document Signed 10/15/2014 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 11/11/2014 1:00 PM
- 2:00 PM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Richard reported that he is having more anxiety after the psychiatrist increased
the dosage of the medications.
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Explored the living situations, explored symptoms and the mood swings, explored
the depressive symptoms and the stress management techniques. Encouraged
for journaling the thoughts and emotions
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Richard was agreeable to the plan
Plan/Additional
Information(Indicate
action plan between
sessions):
To continue seeing him on weekly basis
Goal(s) Addressed
IAP--Outpatient
Problem Mental Health/Illness Management
Goal Richard will decrease his anxiety syptoms
Objective Richard will be able to report less anxiety syptms and reduce by at least 90% .
Intervent-
ion Therapist will assist Richard to work on this thought reconstruction, stress management
skill, exploration of activities that keeps him engaged and decrease the thoughts of the
incidents and improve his health condition over all.
Problem Mental Health/Illness Management
Goal Person Served will establish chemical dependence recovery that leads to improved
physical and mental health.
Objective Person's served current signs and symptoms will be reduced through the
use of appropriate psychiatric medications.
Intervent-
ion Medication Education / Symptom / Illness Management
Goal(s) Addressed:
Client DSM Diagnosis as of 11/11/2014
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 11/11/2014
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1
300.00 - Anxiety Disorder
NOS 300.00 - ANXIETY STATE
NOS 2
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description
Pri/Sec Comments
799.9 - Diagnosis Deferred
on Axis II 799.9 - UNKN CAUSE
MORB/MORT NEC 2
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Mild
Problems with access to health care services Mild lack of outpatient mental health providers
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 50
Signatures
Signature #1: Radha Adhikari (Masters +2) - 11/11/2014 3:46 PM
Signature History
Action Date Staff
Document Signed 11/11/2014 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 11/18/2014 1:00 PM
- 2:00 PM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Richard reported that he is "feeling better this week". However when he learnt
about the response from the med provider, he started repoting that he is not
feeling good and feels like going home and "punching hole on the wall" and
reported he feels like hurting himself rather than hurting others and the
"medication are not right for me".
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect reports thoughts of
hurting himself.
Thought Process/
Orientation
Behavior/
Functioning irritable, restless
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Check all that apply below and record action taken in
Therapeutic Interventions section
Danger To: Ideation Plan Intent Attempt Comments
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Self client reports
thougths of SI
and stated that
he would not
do it as it can
hurt his family
Others
Property
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Safety assesement, contract of safety by the use of Crisis line or natural support,
updated med provider about the client's report through email, reveiwed deep
relaxation discussed during the previous sessions.
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Client is in agreement and reported that he would like to hear what he needs to
do with the medication.
Plan/Additional
Information(Indicate
action plan between
sessions):
To follow up with cleint and med provider as requested by the client
Goal(s) Addressed
IAP--Outpatient
Problem Mental Health/Illness Management
Goal Richard will decrease his anxiety syptoms
Objective Richard will be able to report less anxiety syptms and reduce by at least 90% .
Intervent-
ion Therapist will assist Richard to work on this thought reconstruction, stress management
skill, exploration of activities that keeps him engaged and decrease the thoughts of the
incidents and improve his health condition over all.
Problem Mental Health/Illness Management
Goal Person Served will establish chemical dependence recovery that leads to improved
physical and mental health.
Objective Person's served current signs and symptoms will be reduced through the
use of appropriate psychiatric medications.
Intervent-
ion
Medication Education / Symptom / Illness Management
Goal(s) Addressed:
Client DSM Diagnosis as of 11/18/2014
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 11/18/2014
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1 r/o psychosis
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
301.9 - Personality Disorder
NOS 301.9 - PERSONALITY
DISORDER NOS 2 cluster b , predominant
borderline traits but also
antisocial, and narcissistic
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Severe
Problems with access to health care services Mild feels the doctors are not treating his muscle
pain
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 46
Signatures
Signature #1: Radha Adhikari (Masters +2) - 11/18/2014 2:20 PM
Signature History
Action Date Staff
Document Signed 11/18/2014 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 11/25/2014 1:00 PM
- 2:00 PM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Client reported that "I am doing much better that last time I was here". However
he continues to report depressive symptoms, he reports that the change in the
meds took care of the anxiety.
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Supportive therapy, reviewed diet and nutrition, encouraged to include stress
management skills through Yoga and introduced sun salutation exercises.
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Client reported that he would try and report his experience.
Plan/Additional
Information(Indicate
action plan between
sessions):
To continue working for improving his depressive symptoms
Goal(s) Addressed
IAP--Outpatient
Problem Mental Health/Illness Management
Goal Richard will decrease his anxiety syptoms
Objective Richard will be able to report less anxiety syptms and reduce by at least 90% .
Intervent-
ion Therapist will assist Richard to work on this thought reconstruction, stress management
skill, exploration of activities that keeps him engaged and decrease the thoughts of the
incidents and improve his health condition over all.
Problem Mental Health/Illness Management
Goal Person Served will establish chemical dependence recovery that leads to improved
physical and mental health.
Objective Person's served current signs and symptoms will be reduced through the
use of appropriate psychiatric medications.
Intervent-
ion Medication Education / Symptom / Illness Management
Goal(s) Addressed:
Client DSM Diagnosis as of 11/25/2014
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 11/25/2014
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1 r/o psychosis
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
301.9 - Personality Disorder
NOS
301.9 - PERSONALITY
DISORDER NOS
2 cluster b , predominant
borderline traits but also
antisocial, and narcissistic
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
chronic pain 3
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Severe
Problems with access to health care services Mild feels the doctors are not treating his muscle
pain
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 46
Signatures
Signature #1: Radha Adhikari (Masters +2) - 11/25/2014 2:01 PM
Signature History
Action Date Staff
Document Signed 11/25/2014 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 12/9/2014 8:00 AM
- 9:00 AM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Client reports that with the new medication, "Olanzapine 10 mg" has no change
in his mood. He reports depressed mood as before and the SI thoughts are still
there. When pressed to tell more about it, he says that "I am not noticing any
difference". He also reported that he noticed "more irritable mood on this
medication than last medication". client reported that he is focused on the court
date that is scheduled today.
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning fidgity
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Therapeutic Interventions
Therapeutic
Interventions Delivered Empathetic listening, reviewed safety assessment, redirected to Crisis Services.
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
inSession:
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Richard is agreeable to recommendation
Plan/Additional
Information(Indicate
action plan between
sessions):
To follow up with the med provider
Goal(s) Addressed
IAP--Outpatient
Problem Mental Health/Illness Management
Goal Richard will decrease his anxiety syptoms
Objective Richard will be able to report less anxiety syptms and reduce by at least 90% .
Intervent-
ion
Therapist will assist Richard to work on this thought reconstruction, stress management
skill, exploration of activities that keeps him engaged and decrease the thoughts of the
incidents and improve his health condition over all.
Problem Mental Health/Illness Management
Goal Person Served will establish chemical dependence recovery that leads to improved
physical and mental health.
Objective Person's served current signs and symptoms will be reduced through the
use of appropriate psychiatric medications.
Intervent-
ion Medication Education / Symptom / Illness Management
Goal(s) Addressed:
Client DSM Diagnosis as of 12/9/2014
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 12/9/2014
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1 r/o psychosis
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description
Pri/Sec Comments
301.9 - Personality Disorder
NOS 301.9 - PERSONALITY
DISORDER NOS 2 cluster b , predominant
borderline traits but also
antisocial, and narcissistic
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Severe
Problems with access to health care services Mild feels the doctors are not treating his muscle
pain
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 46
Signatures
Signature #1: Radha Adhikari (Masters +2) - 12/9/2014 11:29 AM
Signature History
Action Date Staff
Document Signed 12/9/2014 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 12/30/2014 10:00 AM
- 11:00 AM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Richard reports that" every thing is same" I feel the same way, nothing is helping
me. client reported having good christmas party and stated that he is planning to
raise a family.
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Validation of feelings, supportive therapy, comparison of being connected with the
providers versus the situation with obsessed thoughts.
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
client agreed with the recommendation, however every other conversation ends
with the court charges
Plan/Additional
Information(Indicate
action plan between
sessions):
To continue following up with the med provider and provide education for the
thought diversion
Goal(s) Addressed
IAP--Outpatient
Problem Mental Health/Illness Management
Goal Richard will decrease his anxiety syptoms
Objective Richard will be able to report less anxiety syptms and reduce by at least 90% .
Intervent-
ion Therapist will assist Richard to work on this thought reconstruction, stress management
skill, exploration of activities that keeps him engaged and decrease the thoughts of the
incidents and improve his health condition over all.
Problem Mental Health/Illness Management
Goal Person Served will establish chemical dependence recovery that leads to improved
physical and mental health.
Objective Person's served current signs and symptoms will be reduced through the
use of appropriate psychiatric medications.
Intervent-
ion Medication Education / Symptom / Illness Management
Goal(s) Addressed:
Client DSM Diagnosis as of 12/30/2014
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 12/30/2014
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1
300.00 - Anxiety Disorder
NOS 300.00 - ANXIETY STATE
NOS 2
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description
Pri/Sec Comments
799.9 - Diagnosis Deferred
on Axis II 799.9 - UNKN CAUSE
MORB/MORT NEC 2
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Mild
Problems with access to health care services Mild lack of outpatient mental health providers
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 50
Signatures
Signature #1: Radha Adhikari (Masters +2) - 12/30/2014 11:00 AM
Signature History
Action Date Staff
Document Signed 12/30/2014 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 1/13/2015 10:00 AM
- 11:00 AM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Richard reports that his case has been put off to trial for March and disablility was
denied for him, this situation led him to feel distressed to the level that he might
be melting down.
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Validation of feelings, reminded about the contract of safety and encouraged him
to bring his wife on board with the plan, CBT skills and thought reconstruction
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Richard is agreeable
Plan/Additional
Information(Indicate
action plan between
sessions):
To continue working with him on CBT skills
Goal(s) Addressed
IAP--Outpatient
Problem Mental Health/Illness Management
Goal Richard will decrease his anxiety syptoms
Objective Richard will be able to report less anxiety syptms and reduce by at least 90% .
Intervent-
ion Therapist will assist Richard to work on this thought reconstruction, stress management
skill, exploration of activities that keeps him engaged and decrease the thoughts of the
incidents and improve his health condition over all.
Problem Mental Health/Illness Management
Goal Person Served will establish chemical dependence recovery that leads to improved
physical and mental health.
Objective Person's served current signs and symptoms will be reduced through the
use of appropriate psychiatric medications.
Intervent-
ion Medication Education / Symptom / Illness Management
Goal(s) Addressed:
Client DSM Diagnosis as of 1/13/2015
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 1/13/2015
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1 r/o psychosis
297.1 - Delusional Disorder 297.1 - DELUSIONAL
DISORDER 2 Unspecified Type; Rule Out
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description
Pri/Sec Comments
301.9 - Personality Disorder
NOS 301.9 - PERSONALITY
DISORDER NOS 2 cluster b , predominant
borderline traits but also
antisocial, and narcissistic
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Severe
Problems with access to health care services Mild feels the doctors are not treating his muscle
pain
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 46
Signatures
Signature #1: Radha Adhikari (Masters +2) - 1/13/2015 11:03 AM
Signature History
Action Date Staff
Document Signed 1/13/2015 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 1/26/2015 11:00 AM
- 12:00 PM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Richard reports that he still has anxiety and has suicidal thoughts, however he
reported that he thinks about his wife and changes his mind. he reprrts he feels
like a leech without being productive especially due to the body ache and the
muscle pain.
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Risk assessment, encouraged to call crisis line to address the suicidal thought
and reevaluate the medication.
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Client is agreeable to the plan
Plan/Additional
Information(Indicate
action plan between
sessions):
To continue monitoring his depressive symtpoms, client will call crisis requesting
for CSU level of care due to his SI thoughts with a plan of cutting his arm and
bleeding to death.
Goal(s) Addressed
IAP--Outpatient
Problem Mental Health/Illness Management
Goal Richard will decrease his anxiety syptoms
Objective Richard will be able to report less anxiety syptms and reduce by at least 90% .
Intervent-
ion Therapist will assist Richard to work on this thought reconstruction, stress management
skill, exploration of activities that keeps him engaged and decrease the thoughts of the
incidents and improve his health condition over all.
Problem Mental Health/Illness Management
Goal Person Served will establish chemical dependence recovery that leads to improved
physical and mental health.
Objective Person's served current signs and symptoms will be reduced through the
use of appropriate psychiatric medications.
Intervent-
ion Medication Education / Symptom / Illness Management
Goal(s) Addressed:
Client DSM Diagnosis as of 1/26/2015
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 1/26/2015
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1
300.00 - Anxiety Disorder
NOS 300.00 - ANXIETY STATE
NOS 2
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description
Pri/Sec Comments
799.9 - Diagnosis Deferred
on Axis II 799.9 - UNKN CAUSE
MORB/MORT NEC 2
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Mild
Problems with access to health care services Mild lack of outpatient mental health providers
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 50
Signatures
Signature #1: Radha Adhikari (Masters +2) - 1/26/2015 12:04 PM
Signature History
Action Date Staff
Document Signed 1/26/2015 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 2/10/2015 1:00 PM
- 2:00 PM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Richard stated that he is feeling very depressed and wants to hurt himself and
pulled out a knife and showed to therapist how he would cut himself without
making a cut, he stated that he thinks that he would go home and take another
knife and hurt himself as he can change his clothes at home.
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Check all that apply below and record action taken in
Therapeutic Interventions section
Danger To: Ideation Plan Intent Attempt Comments
Self Client came
into the
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
session with a
knife and said
how he would
hurt himself
Others
Property
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Safety assesment, took possession of the knife he held, discussed about the
crisis assessment and referred client to crisis and walked him over to the crisis
unit for evalaution.
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Client was cooperative
Plan/Additional
Information(Indicate
action plan between
sessions):
To follow up with the crisis clinician about the disposition.
Goal(s) Addressed
IAP--Outpatient
Problem Mental Health/Illness Management
Goal Richard will decrease his anxiety syptoms
Objective Richard will be able to report less anxiety syptms and reduce by at least 90% .
Intervent-
ion Therapist will assist Richard to work on this thought reconstruction, stress management
skill, exploration of activities that keeps him engaged and decrease the thoughts of the
incidents and improve his health condition over all.
Problem Mental Health/Illness Management
Goal Person Served will establish chemical dependence recovery that leads to improved
physical and mental health.
Objective Person's served current signs and symptoms will be reduced through the
use of appropriate psychiatric medications.
Intervent-
ion Medication Education / Symptom / Illness Management
Goal(s) Addressed: Referral to Crisis Unit
Client DSM Diagnosis as of 2/10/2015
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 2/10/2015
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1 r/o psychosis
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
301.9 - Personality Disorder
NOS 301.9 - PERSONALITY
DISORDER NOS 2 cluster b , predominant
borderline traits but also
antisocial, and narcissistic
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Severe
Problems with access to health care services Mild feels the doctors are not treating his muscle
pain
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 46
Signatures
Signature #1: Radha Adhikari (Masters +2) - 2/10/2015 2:05 PM
Signature History
Action Date Staff
Document Signed 2/10/2015 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 3/3/2015 1:00 PM
- 2:00 PM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
client reports that his anxiety symptoms are better now after the doses of the
medication has been fixed.
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Validation of feelings, gathered information about the psycho social
evnovironment and discussed about the transition plan when this writer is not
available.
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
client was engaing and cooperative
Plan/Additional
Information(Indicate
action plan between
sessions):
Therapist will discuss the case with supervisor in the next meet client will speak
with the med prescriber about the transition plan.
Goal(s) Addressed
IAP--Outpatient
Problem Mental Health/Illness Management
Goal Richard will decrease his anxiety syptoms
Objective Richard will be able to report less anxiety syptms and reduce by at least 90% .
Intervent-
ion Therapist will assist Richard to work on this thought reconstruction, stress management
skill, exploration of activities that keeps him engaged and decrease the thoughts of the
incidents and improve his health condition over all.
Problem Mental Health/Illness Management
Goal Person Served will establish chemical dependence recovery that leads to improved
physical and mental health.
Objective Person's served current signs and symptoms will be reduced through the
use of appropriate psychiatric medications.
Intervent-
ion Medication Education / Symptom / Illness Management
Goal(s) Addressed:
Client DSM Diagnosis as of 3/3/2015
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 3/3/2015
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1
300.00 - Anxiety Disorder
NOS 300.00 - ANXIETY STATE
NOS 2
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description
Pri/Sec Comments
799.9 - Diagnosis Deferred
on Axis II 799.9 - UNKN CAUSE
MORB/MORT NEC 2
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Mild
Problems with access to health care services Mild lack of outpatient mental health providers
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 50
Signatures
Signature #1: Radha Adhikari (Masters +2) - 3/3/2015 9:10 PM
Signature History
Action Date Staff
Document Signed 3/3/2015 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Adhikari, Radha (004049)
Service Date/Time: 3/16/2015 10:30 AM
- 11:30 AM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Client reports improved mood and is able to keep his mind off as he is working on
making models . He stated he would like to talk to his ex boss and try to find if he
can work partime and see if his muscles will support his work
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Coping skills, discussion about the discharge planning and intiiated referral
process with the client.
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Client is in agreement
Plan/Additional
Information(Indicate
action plan between
sessions):
client will continue therapy with Carson Center at Ware and therapist will speak
with the intake coordinator when she calls back. Richard will continue to see
Regina Sanders for medication management
Goal(s) Addressed
IAP--Outpatient
Problem Mental Health/Illness Management
Goal Richard will decrease his anxiety syptoms
Objective Richard will be able to report less anxiety syptms and reduce by at least 90% .
Intervent-
ion Therapist will assist Richard to work on this thought reconstruction, stress management
skill, exploration of activities that keeps him engaged and decrease the thoughts of the
incidents and improve his health condition over all.
Problem Mental Health/Illness Management
Goal Person Served will establish chemical dependence recovery that leads to improved
physical and mental health.
Objective Person's served current signs and symptoms will be reduced through the
use of appropriate psychiatric medications.
Intervent-
ion Medication Education / Symptom / Illness Management
Goal(s) Addressed:
Client DSM Diagnosis as of 3/16/2015
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 3/16/2015
Diagnosis By: Adhikari, Radha (004049)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1
300.00 - Anxiety Disorder
NOS 300.00 - ANXIETY STATE
NOS 2
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description
Pri/Sec Comments
799.9 - Diagnosis Deferred
on Axis II 799.9 - UNKN CAUSE
MORB/MORT NEC 2
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Problems related to interaction with the legal
system/crime Mild
Problems with access to health care services Mild lack of outpatient mental health providers
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 50
Signatures
Signature #1: Radha Adhikari (Masters +2) - 3/16/2015 11:41 AM
Signature History
Action Date Staff
Document Signed 3/16/2015 Radha Adhikari (Masters
+2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Davenport, Leslie (005406)
Service Date/Time: 7/30/2015 10:00 AM
- 11:00 AM
Client Program: Outpatient (OP)
Activity: Individual Therapy (IND TX)
Organization: BHN Center for WellBeing--Springfield
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
Richard states he feels he was forced to come to individual sessions by his
psychiatrist.
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
Therapist utilized Solution-Focused Therapy/MET to help client visualize an area
in his life he wants to see change.
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
This is client's first session; he states he needs to find employment, but it's
difficult for him since he has a felony.
Plan/Additional
Information(Indicate
action plan between
sessions):
Client reports he will continue medical compliance as well as attend scheduled
sessions.
Goal(s) Addressed
IAP--Outpatient
Problem Mental Health/Illness Management
Goal Richard will decrease his anxiety syptoms
Objective Richard will be able to report less anxiety syptms and reduce by at least 90% .
Intervent-
ion Therapist will assist Richard to work on this thought reconstruction, stress management
skill, exploration of activities that keeps him engaged and decrease the thoughts of the
incidents and improve his health condition over all.
Problem Mental Health/Illness Management
Goal Person Served will establish chemical dependence recovery that leads to improved
physical and mental health.
Objective Person's served current signs and symptoms will be reduced through the
use of appropriate psychiatric medications.
Intervent-
ion Medication Education / Symptom / Illness Management
Goal(s) Addressed: Client addressed ways to reduce his anxiety sxs.
Client DSM Diagnosis as of 7/30/2015
Client: Stebbins, Richard (110100) 10/8/1978
Date Diagnosed: 7/30/2015
Diagnosis By: Davenport, Leslie (005406)
External Diagnosis? No
Description:
Diagnostic Formulation
Axis I: Clinical Disorders
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
296.90 - Mood Disorder
NOS 296.90 - EPISODIC MOOD
DISORD NOS 1 r/o psychosis
Axis II: Personality Disorders and Mental Retardation
DSM Code - Description ICD-9 Code - Short
Description Pri/Sec Comments
301.9 - Personality Disorder
NOS 301.9 - PERSONALITY
DISORDER NOS 2 cluster b , predominant
borderline traits but also
antisocial, and narcissistic
Axis III: General Medical Conditions
ICD-9 Code ICD-9 Description Pri/Sec
chronic pain 3
Axis IV: Psychosocial and Environmental Problems
Description Severity Comments
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
Problems related to interaction with the legal
system/crime Severe
Problems with access to health care services Mild feels the doctors are not treating his muscle
pain
Other psychosocial and environment
problems Mild limited coping skills
Economic problems Mod
Axis V: Global Assessment of Functioning Scale
Current GAF Score 46
Signatures
Signature #1: Leslie Davenport (Masters +2) - 7/30/2015 11:16 AM
Signature History
Action Date Staff
Document Signed 7/30/2015 Leslie Davenport
(Masters +2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Session Information
Client: Stebbins, Richard (110100) 10/8/1978
Staff: Mekler, Rebekah (005511)
Service Date/Time: 10/14/2015 10:00 AM
- 11:00 AM
Client Program: Outpatient (OP)
Activity: Diagnostic (DIAG)
Organization: Valley Human Services Outpatient
Service Location: 11 - Office
Psychotherapy Progress Note
Modality: Individual
Family
Couple
List All Persons
Present: Person Present
Person No Show
Person Cancelled
Provider Cancelled
Explanation:
Others Present (please identify name(s) and relationship(s) to Person):
Person's report of
progress towardsgoals/
objectives since last
session:
intake-first session
New Issue(s) Presented
today: None Reported
Person's Condition
Person's
Condition No Significant
ChangesReported
or Observed
Notable Changes in
Person's
Condition
Mood/Affect
Thought Process/
Orientation
Behavior/
Functioning
Medical Condition
Substance Use N/A
Risk Assessment
Danger To: None
Check all that apply below and record action taken in
Therapeutic Interventions section
Danger To: Ideation Plan Intent Attempt Comments
Self
Others
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 1 of 3 Date Printed: 3/26/2025 3:42 PM
Property
Therapeutic Interventions
Therapeutic
Interventions Delivered
inSession:
gathered data for comprehensive assessment. suggested client consider Mass
Rehab for assistance finding work.
Person's Response to
Intervention/
ProgressToward Goals
and Objectives:
Richard reports that he is feeling very anxious but appears to be relaxed. He says
that he internalizes his anxiety and depression, and it is usually undetectable by
others. Richard was recently hospitalized for his third suicide attempt. He spent
two weeks in the hospital in 2004 and 2005. He spent five days at Noble and was
discharged last week. Richard's recent suicide attempt was due to be frustrated
with medical treatment. The last straw was finding out his wife had an affair.
Richard expressed interest in Mass Rehab, as he would very much like to get a
job.
Plan/Additional
Information(Indicate
action plan between
sessions):
recommended that client call the agency in a week if he hasn't received a call
from a clinician
Goal(s) Addressed
No Goal(s) addressed were chosen
Goal(s) Addressed: comprehensive assessment
Client DSM Diagnosis as of 10/14/2015
10:00 AM
Client: Stebbins, Richard (110100) 10/8/1978
Effective Date/Time: 10/14/2015 10:00 AM
External Diagnosis: No
Diagnosed By: Mekler, Rebekah (005511)
Comments:
Diagnosis
DSM-5 Severity/Specifier ICD-10 SNOMED Comments
F33.2 -
Severe
major
depressive
disorder,
recurrent
episode
F33.2 -
Major
depressive
disorder,
recurrent
severe
without
psychotic
features
36474008
F41.9 -
Unspecified
Anxiety
Disorder
F41.9 -
Anxiety
disorder,
unspecified
197480006
The Diagnoses above display in priority order.
Psychosocial and Contextual Factors
ICD-10 Code - Description Comments
No records found.
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 2 of 3 Date Printed: 3/26/2025 3:42 PM
Diagnostic Formulation
Richard reports that he is feeling very anxious but appears to be relaxed. He says that he internalizes his anxiety
and depression, and it is usually undetectable by others. Richard was recently hospitalized for his third suicide
attempt, in which he cut his arm. He also spent two weeks in the hospital in 2004 and 2005. He spent five days at
Noble and was discharged last week. Richard's recent suicide attempt was due to be frustrated with medical
treatment, and finding out that his wife had an affair. He has been diagnosed previously with episodic mood disorder
and an anxiety disorder.
Signatures
Signature #1: Rebekah Mekler (Masters +2) - 10/14/2015 2:56 PM
Signature History
Action Date Staff
Document Signed 10/14/2015 Rebekah Mekler
(Masters +2)
Behavioral Health Network, Inc. -
Psychotherapy Progress Note
Stebbins, Richard (110100) 3 of 3 Date Printed: 3/26/2025 3:42 PM
Medications for the year.
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