<TABLE cellSpacing=1 cellPadding=1 width="100%" border=0><TBODY><TR><TD colSpan=3><P align=center><IMG src="https://www.officemd.net/officemd/datapages/loadImage.asp?imageid=6&timestmp=123"></P></TD></TR><TR><TD><P align=center><STRONG><INPUT type=checkbox>Georgetown</STRONG> 1154 Lexington Road  Building C, Suite A Georgetown KY, 40324 Ph:  (502) 868-7272 Fax: (502) 868-7273</P></TD><TD><P align=center><STRONG><INPUT type=checkbox>London</STRONG> 2645 North Laurel Road Suite B London, KY 40741 Ph:  (606) 712-0043 Fax: (606) 712-4033</P></TD><TD><P align=center><STRONG><INPUT type=checkbox> Louisville</STRONG> 9702 Stonestreet Rd. Medical Office Bldg 1, Suite 120 Louisville, KY 40272 Ph: (502) 749-6249 Fax: (502) 749-9983</P></TD><TD vAlign=top><P align=center><STRONG><INPUT CHECKED type=checkbox>Covington</STRONG> 599 Freedom Park Drive Edgewood, KY 41017 Ph: 859-331-3111 Fax: 859-331-3116</P></TD></TR></TBODY></TABLE><H1 style="TEXT-ALIGN: center">DAP Note</H1><TABLE style="WIDTH: 100%" cellSpacing=1 cellPadding=1 border=0><TBODY><TR><TD><P style="TEXT-ALIGN: center"><STRONG><SPAN style="FONT-SIZE: 14px">Shelby Sherrill (12212)</SPAN></STRONG></P></TD><TD><P style="TEXT-ALIGN: center"><STRONG><SPAN style="FONT-SIZE: 14px">DOB: 10/16/1998 (20)</SPAN></STRONG></P></TD><TD><P style="TEXT-ALIGN: center"><STRONG><SPAN style="FONT-SIZE: 14px">Encounter: 09/20/2019  </SPAN></STRONG></P></TD></TR></TBODY></TABLE>  <H2>Data</H2> <SPAN style="FONT-SIZE: 14px"><B>Session Information:</B>  <B>Time In:</B> 3:</U>09 </U>PM</P> <B>Time Out:</B> 4:</U>03 </U>PM</P>PT participated in individual face to face clinical intake. Therapist used components of MI such as active and reflective listening and validated thoughts and feelings and sued a person=centered approach to hear PT's narrative. See PAA and Clinical intake for further information.  PT presented for GAD, Depression NOS and Cannabis Use Disorder. PT reports about one week of sobriety and an increase in panic attacks and anxiety symptoms.  Therapist reviewed UDS, which was positive for Marijuana, as expected per PT's self report.  PT is a 20 year old, white female, college student with minimal trauma history. <B>Pregnancy Test:</B> Negative<U>Breathalyzer Exam</U><UL><LI>BAC: 0.00%</LI></UL><U>Urine Drug Screening:</U> Continuous urine drug screening necessary due to risk of diversion, relapse, overdose, and/or death.  <LI>Amphetamines: neg</LI><LI>Barbiturates: neg</LI><LI>Benzodiazepines: neg</LI><LI>Cocaine: neg</LI><LI>Marijuana: <FONT color=red>pos</FONT></LI><LI>Methadone: neg</LI><LI>Methamphetamine: neg</LI><LI>Opiates: neg</LI><LI>Oxycodone: neg</LI><LI>Phencyclidine: neg</LI><LI>Ecstasy: neg</LI><LI>Buprenorphine: neg  Temperature: 96° fahrenheit. Control Line: Yes  PH, Urine: 7 Specific Gravity: 1.025  Random Screen: No Supervised: No  Oxidants: Neg </SPAN></P> <SPAN style="FONT-SIZE: 14px"> </SPAN> </P><H2>Assessment</H2> <SPAN style="FONT-SIZE: 14px"> <B>Mental Status Exam</B></P></LI><UL><LI>Appearance: appropriate dress and grooming</LI><LI>Sensorium: alert and oriented X4</LI><LI>Behavior: tearful</LI><LI>Motor Activity: unremarkable</LI><LI>Eye Contact: adequate</LI><LI>Speech: normal</LI><LI>Mood: neutral</LI><LI>Affect: congruent with normal range</LI><LI>Thought Flow: linear</LI><LI>Thought Flow: unremarkable</LI><LI>Cognition: normal</LI><LI>Insight: intact</LI><LI>Reliability: apparently reliable</LI></UL><B>Diagnosis</B><UL><LI>F1210: Cannabis abuse, uncomplicated </LI></UL><B>Procedures</B><UL><LI>80305: Urine Drug Screen</LI><LI>81025: URINE PREGNANCY TEST, VISUAL COLOR COMPARISON METHODS</LI><LI>82075: ASSAY OF ALCOHOL (ETHANOL); BREATH</LI><LI>96150: assessment health and behavior</LI><LI>99408: PAA (preadmission assessment)</LI></UL></SPAN><H2>Plan</H2><SPAN style="FONT-SIZE: 14px"> <B>Plan</B> PT to attend individual session next week and work on MTP.  </SPAN></LI>