PRESENTING PROBLEM(S)
* The client reports persistent feelings of anxiety and overwhelming stress related to recent job loss and ongoing marital conflict. They express a sense of worthlessness and difficulty concentrating, leading to social withdrawal.
* Client feels a significant loss of control over their life and is seeking strategies to manage their emotional distress and improve their relationships.
HISTORY OF PRESENTING PROBLEM(S)
* Onset of symptoms approximately 6 months ago, coinciding with initial discussions of company redundancies at work.
* Anxiety initially manifested as mild worry, progressing to daily panic attacks and constant rumination following job termination 2 months ago.
* Marital conflict, although present for several years, has significantly escalated in the past 3 months, with increased arguments and emotional distance from spouse.
* Severity of symptoms fluctuates, but generally high, impacting daily functioning and leading to frequent crying spells.
CURRENT FUNCTIONING
Home Environment:
* The client lives with their spouse in a rented flat. The home environment is currently tense due to marital issues. They report feeling emotionally isolated at home.
Sleep:
* Difficulty falling asleep and staying asleep, often waking multiple times during the night.
* Reports waking feeling unrefreshed, averaging 4-5 hours of disturbed sleep per night.
* The client states that racing thoughts about their job and marriage prevent them from relaxing.
Education:
* The client holds a Bachelor's degree in Business Administration.
* No current educational pursuits.
Employment:
* Recently made redundant from a marketing management position, which they held for 10 years.
* Currently unemployed and actively searching for new opportunities, but reports feeling demotivated and overwhelmed by the job search process.
Family:
* Spouse, Alex (45 years old): Relationship is strained, characterised by frequent arguments and a lack of emotional intimacy.
* No children.
* The client reports limited contact with their parents, who live in a different city, and a distant relationship with their sibling.
Gender and Sexuality:
* The client identifies as female and heterosexual.
* Reports decreased sexual activity and intimacy due to current emotional distress.
* Uses combined oral contraceptive pill.
Culture/Religion/Spirituality:
* The client identifies as agnostic but grew up in a Christian household. No current religious or spiritual practices.
Social:
* Reduced social interactions significantly since the onset of symptoms.
* Has a small circle of friends, but has been cancelling plans frequently due to lack of energy and interest.
* Feels supported by one close friend, but struggles to open up about the full extent of their difficulties.
Exercise/Physical Activity:
* Previously engaged in regular gym workouts (3 times a week) but has ceased this entirely in the past 3 months.
* Reports feeling too fatigued and unmotivated to exercise.
Eating Regime/Appetite:
* Reports irregular eating patterns, often skipping meals or eating convenience food.
* Experiences a fluctuating appetite, sometimes overeating and other times having no desire to eat.
* No history or current signs of disordered eating or eating disorder.
Energy Levels:
* Consistently low energy levels throughout the day, particularly in the mornings.
* Reports feeling drained even after minimal activity, which impacts their ability to engage in daily tasks.
Recreational/Interests/Activities:
* Previously enjoyed reading, painting, and gardening, but has lost interest in these hobbies.
* Spends most of their free time at home, often watching television or scrolling on social media.
Substance Use:
* Reports drinking alcohol (wine) 3-4 times a week, typically 2-3 glasses per occasion, as a way to cope with stress.
* Denies tobacco or illicit drug use.
Legal Issues:
* No current legal issues.
MEDICATIONS
Current Medications: None
Past Medications: None
PSYCHIATRIC HISTORY
* No prior psychiatric hospitalisations.
* Saw a counsellor briefly for 3 sessions five years ago following a bereavement, which they found moderately helpful.
Other interventions: None
Family:
* Maternal aunt diagnosed with generalised anxiety disorder, managed with medication.
MEDICAL HISTORY
Personal Medical History:
* Diagnosed with mild irritable bowel syndrome (IBS) managed with diet.
* No other significant medical conditions.
Family Medical History:
* Father: Hypertension, well-controlled with medication.
* Mother: Type 2 Diabetes.
DEVELOPMENTAL, SOCIAL AND FAMILY HISTORY
Family:
* The client is the eldest of two children. Parents, Sarah (70, retired teacher) and David (72, retired engineer), had a generally stable relationship but often avoided conflict. Sibling, Mark (42, architect), with whom the client has a cordial but not close relationship.
Developmental History:
* Achieved developmental milestones within normal ranges.
* No reported early childhood issues or trauma.
Gender and Sexuality:
* Early relationships were stable but often involved the client prioritising partners' needs over their own.
* No history of sexual health issues.
Relationship History:
* Prior to marriage, had two significant long-term relationships, both ending due to a lack of compatibility and the client's tendency to people-please.
* Reports a pattern of seeking approval from partners.
Educational History:
* Consistently achieved good grades throughout primary and secondary school.
* Attended university and completed a Bachelor's degree, maintaining strong academic performance.
* Described as a diligent and conscientious student.
Employment History:
* Held various marketing roles, progressing steadily in their career until the recent redundancy.
* Generally positive employment history, but recalls experiencing high levels of work-related stress in previous roles, which they often internalised.
Legal History:
* No legal history.
Substance Use:
* Experimented with cannabis a few times in university but ceased use shortly thereafter.
* No history of problematic substance use prior to current increase in alcohol consumption.
RISK ASSESSMENT
Lowered Mood/Anxiety/Depression:
* Client reports significant lowered mood, feelings of sadness, and hopelessness.
* Experiences anxiety daily, including panic attacks.
* Denies current self-harm.
Anger:
* Reports increased irritability and occasional outbursts of anger towards their spouse, which is uncharacteristic.
* Expresses frustration with themselves and their situation.
Safety:
* Expresses concerns about their emotional well-being and ability to cope with current stressors.
* No immediate threats to personal safety.
Suicidal Ideation:
* Denies current suicidal thoughts, intent, or plans.
* Denies history of suicide attempts.
* Expresses a desire to live and improve their situation.
Homicidal Ideation:
* Denies homicidal ideation.
Self-harm (NSSH):
* Denies history of self-harm.
Violence & Aggression:
* No history of physical violence or aggression towards others. Recent verbal aggression towards spouse is an anomaly for the client.
Risk-taking/Impulsivity:
* No current risk-taking behaviours or impulsivity reported.
DIAGNOSIS
* Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.23)
CLINICAL FORMULATION
Presenting Problem:
* The client presents with symptoms of anxiety, low mood, and marital discord following recent job loss.
* Significant impact on daily functioning, sleep, social engagement, and personal interests.
Predisposing Factors:
* History of internalising stress and people-pleasing tendencies in relationships.
* Family history of anxiety.
* Tendency to avoid conflict.
Precipitating Factors:
* Job loss 2 months ago.
* Escalation of pre-existing marital conflict in the last 3 months.
Perpetuating Factors:
* Social withdrawal and isolation.
* Ineffective coping mechanisms, including increased alcohol consumption.
* Negative self-talk and rumination.
* Avoidance of marital communication.
Protective Factors:
* Has one supportive friend.
* Good educational and employment history indicates resilience and capability.
* Insight into their current struggles and motivation to seek help.
Case Formulation:
Client presents with persistent anxiety, low mood, and marital discord, which appears to be precipitated by recent job loss and escalating marital conflict. Factors that predisposed the client to the problem include a history of internalising stress, people-pleasing tendencies, and a family history of anxiety. The current problem is maintained by social withdrawal, ineffective coping mechanisms such as increased alcohol consumption, negative self-talk, and avoidance of marital communication. However, the protective and positive factors include a supportive friend, a history of resilience and capability, and insight into their current struggles with a motivation to seek help.
PRESENTING PROBLEM(S)
[presenting problems] (Use as many bullet points as needed to capture the reason for the visit and any associated stressors in detail. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
HISTORY OF PRESENTING PROBLEM(S)
[history of presenting problems] (Include onset, duration, course, and severity of the symptoms or problems. Use as many bullet points as needed to capture when the symptoms or problem started, the development and course of symptoms. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
CURRENT FUNCTIONING
Home Environment:
[home environment] (Describe current living situation, family dynamics, relationships with family members. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Sleep:
[sleep patterns] (Use as many bullet points as needed to capture the sleep pattern and how the problem has affected sleep patterns. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Education:
[education] (Detail current educational status, including academic achievement, school performance, attendance, relationships with teachers and peers, and any issues. Use as many bullet points as needed to capture current education information and how the symptoms or problem has affected education. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Employment:
[employment] (Use as many bullet points as needed to capture current employment status and how the symptoms or problem has affected current employment. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Family:
[family dynamics] (Use as many bullet points as needed to capture names, ages of family members and the relationships with each other and the effect of symptoms on the family dynamics and relationships. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Gender and Sexuality:
[gender and sexuality] (Describe current gender, sexual activity, sexual orientation, relationships, contraception use, and sexual health. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Culture/Religion/Spirituality:
[culture, religion, or spirituality] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Social:
[social interactions] (Use as many bullet points as needed to capture the social interactions of the client and the client's support network. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Exercise/Physical Activity:
[exercise and physical activity] (Use as many bullet points as needed to capture all exercise and physical activity and the effect the symptoms have had on the client's exercise and physical activity. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Eating Regime/Appetite:
[eating habits and appetite] (Include disordered eating or eating disorder information. Use as many bullet points as needed to capture all eating habits and appetite and the effect the symptoms have had on the client's eating habits and appetite. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Energy Levels:
[energy levels] (Use as many bullet points as needed to capture the client's energy levels throughout the day and the effect the symptoms or problems have had on the client's energy levels. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Recreational/Interests/Activities:
[hobbies and interests] (Mention hobbies, interests, or extracurricular activities and the effect the client's symptoms have had on their hobbies and interests. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Substance Use:
[substance use] (Mention current use of tobacco, alcohol, and other substances, frequency and context of use. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Legal Issues:
[legal issues] (Detail any current family court or legal issues. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
MEDICATIONS
Current Medications: [current medications] (List type, frequency, and daily dose in detail. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Past Medications: [past medications] (List past type, frequency, and daily dose in detail. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
PSYCHIATRIC HISTORY
[psychiatric history] (Detail any psychiatric history including hospitalisations, treatment from psychiatrists, psychological treatment, counselling. Use as many bullet points as needed. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Other interventions: [other interventions] (Detail any other interventions not mentioned in Psychiatric History. Use as many bullet points as needed. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Family:
[family psychiatric history] (Detail family history of any psychiatric history including hospitalisations, medications, treatment from psychiatrists, psychological treatment, counselling. Use as many bullet points as needed. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
MEDICAL HISTORY
Personal Medical History: [personal medical history] (Use as many bullet points as needed to capture the client's medical history. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Family Medical History: [family medical history] (Use as many bullet points as needed to capture the client's family medical history. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
DEVELOPMENTAL, SOCIAL AND FAMILY HISTORY
Family:
[family of origin] (Use as many bullet points as needed to capture the client's family at birth, including parents' names, their occupations, the parents' relationship with each other, and other siblings. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Developmental History:
[developmental milestones] (Use as many bullet points as needed to capture developmental history and any issues. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Gender and Sexuality:
[past gender and sexuality] (Describe past gender, sexual activity, orientation, relationships, contraception use, and sexual health issues. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Relationship History:
[relationship history] (Use as many bullet points as needed to capture the relationship history and any issues. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Educational History:
[educational history] (Detail educational history, including academic achievement, school performance, attendance, relationships with teachers and peers, and any issues. Use as many bullet points as needed. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Employment History:
[employment history] (Use as many bullet points as needed to capture employment history and any issues. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Legal History:
[legal history] (Detail any forensic, family court or legal history. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Substance Use:
[past substance use] (Use as many bullet points as needed to capture past substance use including type and frequency. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
RISK ASSESSMENT
Lowered Mood/Anxiety/Depression:
[mood and anxiety] (Mention any feelings of anxiety, lowered mood, sadness, hopelessness, or self-harm. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Anger:
[anger] (Mention any issues past or current with anger and how anger has affected their lives. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Safety:
[safety concerns] (Describe any concerns about personal safety, experiences with violence or abuse, safety at home, school, or work. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Suicidal Ideation:
[suicidal ideation] (History, attempts, current suicidal thoughts, suicide intent or plans and if there are any safety plans in place. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Homicidal Ideation:
[homicidal ideation] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Self-harm (NSSH):
[self-harm history] (Detail any history of self-harm. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Violence & Aggression:
[violence and aggression] (Describe any incidents of violence or aggression. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Risk-taking/Impulsivity:
[risk-taking behaviours] (Describe any risk-taking behaviours or impulsivity. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
DIAGNOSIS
[diagnosis] (List any DSM-5-TR diagnosis and any comorbid conditions. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
CLINICAL FORMULATION
Presenting Problem:
[presenting problem summary] (Summarise the presenting problem. Use as many bullet points as needed. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Predisposing Factors:
[predisposing factors] (List predisposing factors to the client's condition. Use as many bullet points as needed. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Precipitating Factors:
[precipitating factors] (List precipitating factors that may have triggered the condition. Use as many bullet points as needed. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Perpetuating Factors:
[perpetuating factors] (List factors that are perpetuating the condition. Use as many bullet points as needed. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Protective Factors:
[protective factors] (List factors that protect the client from worsening of the condition. Use as many bullet points as needed. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Case Formulation:
[case formulation paragraph] (Write as a single paragraph following this structure: Client presents with the problem, which appears to be precipitated by the precipitating factors. Factors that predisposed the client to the problem include the predisposing factors. The current problem is maintained by the perpetuating factors. However, the protective and positive factors include the protective factors. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
(This template is for first appointments with counselling clients. Always use "client" instead of "patient" or their name. Always use Australian English spelling. Write in detailed bullet points. Do not use quotes. Topics discussed in counselling transcripts may vary greatly and are not always well-defined clinical conditions — they are often aspects of the client's life important to them. Use the entire transcript and include all relevant details. Use the placeholders above as a guide, but use clinical judgement to exclude irrelevant sections or include new sections not in the template to accurately capture the topics discussed.)
