Initial session

CONFIDENTIALITY Confidentiality and the limits to confidentiality were discussed. Client and their caregiver reported to understand. The psychologist discussed requests for additional support, including though not limited to, letters, reports, emails and/or phone calls to third parties. Client and/or their caregiver were advised of the fee structure associated with such requests. Client and/or their caregiver reported to understand. REFERRAL AND/OR FUNDING INFORMATION Client is eligible for NDIS funding and this was discussed. MENTAL STATUS EXAM Appearance: Client presented as well-groomed and appropriately dressed for the weather. Behaviour: Client was cooperative and engaged throughout the session. Speech: Speech was clear, coherent, and of normal rate and rhythm. Mood: Client reported a low mood. Affect: Affect was congruent with reported mood. Thought process: Thought process was linear and goal-directed. Orientation: Client was oriented to person, time, and place. PREVIOUS/CURRENT ENGAGEMENT WITH SERVICES - Client reported no previous engagement with psychologist. - Client reported no historical and/or current engagement with allied health services. DIAGNOSTIC INFORMATION Client has received a diagnosis of Major Depressive Disorder. CURRENT MEDICATIONS Client reported taking Sertraline 100mg daily. CHIEF CONCERNS Client reports feeling sad most days, with a loss of interest in activities they used to enjoy. They also report difficulty sleeping and changes in appetite. CURRENT FUNCTIONING Sleep: Client reports difficulty falling asleep and staying asleep, averaging 5-6 hours of sleep per night. Social: Client reports withdrawing from social activities and feeling isolated. Exercise/Physical Activity: Client reports a decrease in physical activity due to low energy levels. Eating Regime/Appetite: Client reports a decreased appetite and weight loss. Energy Levels: Client reports low energy levels throughout the day. Recreational/Interests: Client reports a loss of interest in hobbies such as painting. HISTORY Family history: Mother has a history of depression. HOME ENVIRONMENT Family: Client lives with their mother and father. SCHOOL ENVIRONMENT School: St. Mary's High School Year: Year 10 Academic and behavioural presentation: Client's grades have declined recently, and they have been missing school more frequently. RISK ASSESSMENT Suicidal ideation: no Self-harming behaviours: no CLIENT GOALS Client wants to improve their mood, increase their energy levels, and re-engage in activities they enjoy. TREATMENT PLAN - Cognitive Behavioral Therapy (CBT) to address negative thought patterns. - Activity scheduling to increase engagement in pleasurable activities. - Psychoeducation on depression and coping strategies. PSYCHOEDUCATION - Provided information on the nature of depression. - Discussed the role of thoughts, feelings, and behaviours. - Introduced coping strategies such as relaxation techniques. NEXT SESSION Next appointment scheduled for 8 November 2024 at 10:00 AM.