Individual Therapy

Paid Late Entry
Service Date: Feb 13, 2026 CPT: 90834 Duration: 45 min

Patient

Maria Gonzalez

Generalized anxiety disorder

Provider

Amanda Foster, LPC-MHSP

LPC-MHSP

NPI: 3456789012

S

Subjective

Client reports moderate anxiety levels this week. Work deadlines contributing to worry. Using breathing exercises daily. Reports satisfaction with therapy progress overall.

O

Objective

Client appropriately dressed, on time. Affect mildly anxious. Speech normal rate. Engaged in session. Demonstrated diaphragmatic breathing technique correctly. GAD-7 score: 10 (moderate).

A

Assessment

GAD symptoms remain moderate but stable. Client is building effective coping skills repertoire. Work-related triggers are predictable and targetable through cognitive restructuring.

P

Plan

Continue biweekly therapy. Introduce thought record for work worry. Practice progressive muscle relaxation. Next session: 02/28/2026.

Signatures

Signed by Amanda Foster, LPC-MHSP

Feb 14, 2026, 10:00 AM

Billing Status

Claim ID BIL-008
Payer Aetna
Amount Billed $118
Status Denied
0