CONSULTATION REPORT,
Sarah Jones was seen for an initial psychiatry assessment at the Children's Mental Health Clinic, on 1 November 2024, accompanied by her mother, Mrs. Jones.
ID: Sarah Jones is a 14-year-old female who lives in Toronto with her mother and her dog, Max. Sarah is registered in Grade 9 at Maplewood High School.
Sources of Information:
• Separate and joint interviews with Sarah Jones and Mrs. Jones
• Review of Connect care and Netcare
• Case discussion with nurse, Emily Carter, who assisted with collateral information
• Psychometric measures completed and reviewed
**Reason for referral:**
Referred by Dr. Smith due to concerns about Sarah's persistent low mood and social withdrawal.
**Presenting Complaints:**
1. Low mood for the past 6 months, "I just don't feel happy anymore."
2. Social withdrawal, avoiding friends and activities she used to enjoy.
3. Difficulty sleeping, experiencing insomnia most nights.
**History of Presenting Complaints:**
Sarah reports feeling sad and down most days for the past six months. She states that she has lost interest in activities she used to enjoy, such as playing soccer and spending time with friends. She has withdrawn from social activities and spends most of her time in her room. She reports difficulty falling asleep and staying asleep, often feeling tired during the day. She denies any history of hallucinations, psychosis, or mania.
Collateral History: (Mrs. Jones, Mother)
Mrs. Jones reports that Sarah's mood has been declining gradually over the past six months. She has noticed a significant change in Sarah's behaviour, including social withdrawal, decreased appetite, and difficulty sleeping. Mrs. Jones is concerned about Sarah's well-being and is seeking help to address these issues. She reports that Sarah has no previous mental health concerns and is compliant with all medical appointments.
**Past psychiatric history:**
None reported.
Developmental History:
No issues reported.
Medical History:
No chronic medical conditions reported.
Medication History:
No current medications.
No known allergies.
**Family History:**
Mother reports a history of depression in her maternal grandmother. No history of suicide in the family.
Living arrangements: Sarah lives with her mother. The relationship is generally supportive, although there have been some recent conflicts related to Sarah's mood and behaviour.
Educational History:
Sarah is in Grade 9 at Maplewood High School. Her attendance has been regular, but her grades have declined recently. She is not currently receiving any academic supports. She has not had any behavioral problems at school.
**Social History:**
Sarah is a student. She denies any substance use. She has a few close friends, but she has been avoiding them recently. She enjoys playing soccer, but has stopped playing. She has no vocational goals at this time.
Premorbid Personality:
Sarah was previously described as a happy, outgoing, and well-adjusted teenager.
Expectations:
Parent:
Mrs. Jones hopes that Sarah will feel better and be able to return to her normal activities.
Child:
Sarah wishes to feel happy again and to be able to enjoy her life.
Trauma History/ ACEs:
No adverse childhood experiences identified.
Mental Status Examination:
- Appearance: Sarah is dressed in casual clothing and appears her stated age. Her hygiene is appropriate.
- Behaviour: Sarah is withdrawn and appears sad. She makes limited eye contact.
- Speech: Speech is normal in rate and volume. Speech is coherent.
- Mood: Sarah reports feeling sad.
- Affect: Affect is congruent with mood, appearing sad and constricted.
- Thoughts: No evidence of thought disorder. No suicidal ideation reported.
- Perceptions: No hallucinations reported.
- Cognition: Oriented to time, place, and person. Memory intact.
- Insight: Sarah acknowledges that she is experiencing difficulties and is seeking help.
- Judgment: Judgment appears intact.
**Risk Assessment:**
- No current suicidal or homicidal ideation reported.
Psychometric measures:
PHQ-9 score of 18, indicating moderate depression.
**Impression:**
Sarah Jones, a 14-year-old female, presents with a six-month history of low mood, social withdrawal, and sleep difficulties. Biopsychosocial formulation reveals predisposing factors including a family history of depression, precipitating factors including a recent decline in academic performance, perpetuating factors including social isolation, and protective factors including a supportive family environment.
**DSM-5 Diagnosis:**
Major Depressive Disorder, single episode.
Treatment Plan:
1. Provided psychoeducation in relation to above formulation/ diagnoses and treatment options
- Medications: Discussed the use of antidepressant medication and referred to a paediatrician for further assessment.
- Psychotherapy: Referred to individual therapy with a focus on cognitive-behavioral therapy (CBT).
- Follow-up appointments and referrals: Scheduled a follow-up appointment in 4 weeks.
CONSULTATION REPORT,
[insert name of patient] was seen for an initial psychiatry assessment at the [clinic name], on [insert today's date], accompanied by [insert who patient attended with (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)].
ID: [insert name of patient] is a [age and gender of patient] who lives in [name of city] with [insert who they live with and pets (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]. [insert name of patient] is registered in [insert name of school and grade level (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)].
Sources of Information:
• Separate and joint interviews with [insert name of patient] and [insert who patient attended with (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
• Review of Connect care and Netcare
• Case discussion with nurse, [name], who assisted with collateral information
• Psychometric measures completed and reviewed
**Reason for referral:**
[Name of doctor and reason for referral]
**Presenting Complaints:**
[List main concerns and duration, maximum 3 in total, Ideally include a direct quote per item that captures the main focus of the visit (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
**History of Presenting Complaints:**
This should capture information reported by the patient only and confirmed by the interviewer
[Describe current psychiatric concerns with all available details, reasons for visit, complete history of presenting complaints etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Describe any other associated symptoms with details (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Note if patient denies any history of hallucinations, psychosis, mania, OCD (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]. Can include some direct quotes.
Include anything about functional impairment and, or disability mentioned.
Collateral History: [Write name of individual and role in child's life in bracket]
Write information provided by the individual who accompanies patient, such as mother or father or social worker. Identify who provided the information in the notes. Include any mental health concerns or improvements, medication compliance, side effects of any. Only include what is explicitly stated
**Past psychiatric history:**
[Describe past psychiatric diagnoses, treatments, counselling, psychotherapy and hospitalizations, CFS involvement (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Developmental History:
[Describe pregnancy term and delivery type (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Note if any drug or alcohol exposure in pregnancy (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Describe developmental milestones and note any delays (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Medical History:
[List chronic medical conditions (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[List any history of surgery (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Medication History:
[List current medications and dosages (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[List medication or other allergies (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[List past medication trials, dosage, duration, effectiveness and side effects, reason for discontinuation (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
**Family History:**
[Note any psychiatric illnesses within the family, specifying the relationship to the patient and the nature of the illnesses, any history of suicide (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Describe living arrangements, who else is living at home with patient and quality of relationships (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Educational History:
[Note patient's grade level at school (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Note frequency of attendance if regular or not, absences (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Note academic difficulties and if receiving any supports (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Note behavioral problems at school, suspensions, expulsions (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
**Social History:**
[Occupation, level of education (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[substance use such as smoking, alcohol, recreational drugs (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]. Include any mentions of current or prior use and any treatment for substance use, consequences of substance use. If none endorsed, indicate this.
[Romantic relationship if any (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[social support (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[mention hobbies, part time or full time work, future vocational goals or post secondary ideas (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[mention any legal or forensic history (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Premorbid Personality:
[individual's personality or day to day functioning before they got unwell (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Expectations:
Parent:
[List parent expectation for their child assessment or treatment when asked directly (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Child:
[List wishes expressed by the patient when asked directly (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Trauma History/ ACEs:
[List any of the 10 adverse childhood experiences ACEs identified (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Mental Status Examination:
[Always write information gathered below together in prose/ paragraph format, not as a list]
- Appearance: [Describe the patient's clothing, hygiene, and any notable physical characteristics (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- Behaviour: [Observe the patient's activity level, interaction with their surroundings, and any unique or notable behaviors (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- Speech: [Note the rate, volume, clarity, and coherence of the patient's speech (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- Mood: [Record the patient's self-described emotional state, using their own words if possible (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- Affect: [Describe the range and appropriateness of the patient's emotional response during the examination, noting any discrepancies with the stated mood (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- Thoughts: [Assess the patient's thought process and thought content, noting any distortions, delusions, or preoccupations (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- Perceptions: [Note any reported hallucinations or sensory misinterpretations, specifying type and impact on the patient (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- Cognition: [Describe the patient's memory, orientation to time/place/person, concentration, and comprehension (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- Insight: [Describe the patient's understanding of their own condition and symptoms, noting any lack of awareness or denial (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- Judgment: [Describe the patient's decision-making ability and understanding of the consequences of their actions (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
**Risk Assessment:**
- [Suicidality, homicidality, other risks (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Psychometric measures:
If any rating scales were mentioned such as the PHQ-9, CADDRA Weiss Symptom Record, BDI, SCARED questionnaire -include the score and the interpretation of the score If any lab values, data (such as data from a sleep tracking app) or other test results were reviewed include the details here. [Include as a list (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
**Impression:**
[Under the heading of impression, summarize presenting complaints in a maximum of 2 sentences indicating onset and duration, if stated in transcript and followed by biopsychosocial formulation in full sentences elaborating on predisposing, precipitating, perpetuating and protective factors (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
**DSM-5 Diagnosis:**
[DSM-5 criteria, psychological scales/questionnaires (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Treatment Plan:
List in numeric form 1, 2, 3 and so on.
1. Provided psychoeducation in relation to above formulation/ diagnoses and treatment options
- [Investigations (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [medications (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [psychotherapy (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [family meetings & collateral information, psychosocial interventions (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [follow-up appointments and referrals (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Safety Plan: [If applicable, detailing steps to take in crisis (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
