Client initial assessment

Mode of delivery: In-person Location: Home Consent form completed: Yes AI consent: Yes Referral: Self-referred General introduction and history: The client, [insert age] years old, presents with a history of moderate depression and anxiety, exacerbated by recent job loss. She reports feeling overwhelmed and struggling to cope with daily tasks. Mental Status Examination: Appearance: Appears her stated age, well-groomed, and dressed appropriately. Behaviour: Cooperative and engaged during the session. Speech: Normal rate and rhythm, with no significant abnormalities. Language: Fluent and coherent. Mood and Affect: Reports low mood and anxious affect, congruent with her reported experiences. Thought Content: Reports negative self-talk and worry about the future. Perception: No reported hallucinations or delusions. Cognition: Oriented to person, place, and time. Memory intact. Insight and Judgement: Demonstrates some insight into her difficulties and acknowledges the need for support. Judgement appears intact. Session content: The session focused on exploring the client's current stressors, identifying coping mechanisms, and developing a plan for managing her symptoms. Biological/Medical/Physical issues: Reports difficulty sleeping and decreased appetite. Psychological Issues: Symptoms * Depression * Anxiety Current Stressors: * Job loss * Financial concerns * Relationship difficulties Other: Family history/structure: Client is single, with no children. She has a supportive relationship with her parents. Family history of mental health issues: Mother has a history of anxiety. Relationship status: Single Occupation: Unemployed Financial situation / Income: Limited income, experiencing financial stress. Sports / Exercise: Walks for 30 minutes, three times a week. Interests / Hobbies / other activities: Enjoys reading and spending time in nature. Social: Has a small circle of close friends. Sexuality: Heterosexual Religion: Non-religious Psychiatric History: Previously diagnosed with depression and anxiety. Has tried medication in the past. Sleep: Average 6 hours of sleep. Reports onset insomnia. Appetite: Decreased appetite. Substances: No use of drugs or tobacco. Drinks alcohol occasionally. Medications: Currently not taking any psychiatric medications. Trauma / Abuse / Loss / Neglect: No reported history of trauma or abuse. Previous Self-harm / suicide attempt: No history of self-harm or suicide attempts. Current Self-harm / suicidal ideation: No current suicidal ideation. Future Orientation: Expresses a desire to find a new job and improve her mental health. Overall Risk: * Future oriented * Adequately supported * No recent suicidal ideation Safety Plan: Client has identified her mother as someone she can contact if feeling overwhelmed. Case Formulation: Pre-disposing Factors: * Psychological: History of anxiety and depression. Precipitating Factors: * Social: Job loss and financial stressors. Perpetuating Factors: * Psychological: Negative self-talk and maladaptive coping mechanisms. Protective Factors: * Psychological: Resilience and willingness to seek help. * Social: Supportive family and friends. Supports: * Mother * Friends Triggers: * Financial stress * Social isolation Current coping strategies: * Spending time with friends * Reading * Walking Overall Impression: The client presents with moderate depression and anxiety, exacerbated by recent stressors. She demonstrates resilience and a willingness to engage in therapy. Treatment goals include symptom management, coping skill development, and addressing underlying issues. Current signs / symptoms: Depression: * Low Mood * Loss of interest in activities * Sleep Disruption * Low Energy * Feeling Worthless * Diminished Concentration Anxiety: * Excessive Worry most days * Difficulty Concentrating * Sleep Disturbance Diagnosis: Psychologist diagnosis: Major Depressive Disorder, Generalized Anxiety Disorder ICD-11: 6A80, 6B00 DSM-5: 296.2x, 300.02 Interventions: * Psychoeducation about depression and anxiety. * Exploration of coping mechanisms. * Cognitive restructuring techniques. Plan: * Cognitive Behavioural Therapy Client Treatment Goals: * Reduce symptoms of depression and anxiety. * Develop effective coping strategies. * Improve mood and overall well-being. Homework: * Practice relaxation techniques daily. * Keep a mood journal. * Identify and challenge negative thoughts. Further Appointments: 1 week Follow up: * Review progress on treatment goals. * Assess for any changes in symptoms. * Adjust treatment plan as needed. Date: 1 November 2024