Psychologist's First Session

**PRESENTING PROBLEM(S)** - [describe current issues including sleep disturbances, irritability, anger outbursts, feelings of being overwhelmed, inability to control emotional responses, feeling disproportionately upset by small things, flashbacks, and vivid dreams related to past traumatic experiences] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) **HISTORY OF PRESENTING PROBLEM(S)** - [document onset and progression of symptoms, current medications, and patterns of symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) **CURRENT FUNCTIONING** - Sleep: [describe current sleep patterns, difficulties with falling or staying asleep, and any impact of medications on sleep] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) - Employment/Education: [describe current employment or educational status and any relevant details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) - Family: [describe family situation, relationships, and any significant family history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) - Social: [describe social situation, recent relocations, and any relevant social history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) **PSYCHIATRIC HISTORY** - Psychiatric History: [document any current psychiatric medications, previous counselling or psychological treatment, and any relevant psychiatric history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) **DEVELOPMENTAL, SOCIAL AND FAMILY HISTORY** **Family:** - [describe family background, significant family events, relationships with family members, and any relevant developmental history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) **SUBSTANCE USE** - [document any substance use or lack thereof] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) **SELF-HARM** - [document any current or past self-harm behaviors or lack thereof] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) **RELEVANT CULTURAL/RELIGIOUS/SPIRITUAL ISSUES** - Relevant Cultural/Religious/Spiritual Issues: [describe any relevant cultural, religious, or spiritual issues, including involvement with religious communities and the role of faith in coping] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) **5P FORMULATION** - Presenting Problem: [summarize the main presenting problems] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) - Predisposing Factors: [describe factors that may have predisposed the client to the current problems, including family history and past experiences] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) - Precipitating Factors: [describe recent events or changes that may have triggered the current problems] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) - Perpetuating Factors: [describe factors that may be maintaining the current problems, including difficulties in expressing emotions and unprocessed grief] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) - Protecting Factors: [describe factors that may be helping to protect the client from worsening symptoms, including support systems and coping mechanisms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) **CASE FORMULATION** [provide a comprehensive summary of the client's presenting problems, predisposing factors, precipitating factors, perpetuating factors, and protecting factors] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) **INTERVENTION** - [document the interventions discussed or implemented during the session, including any techniques introduced, strategies discussed, and recommendations made] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) **GOALS** - [list the goals for treatment, including improvements in specific symptoms and development of coping strategies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) **NEXT STEPS** - [outline the next steps in the treatment plan, including any recommended readings, techniques to explore, and strategies to practice] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) **NEXT APPOINTMENT** - [document the details of the next appointment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points with "-".) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points with "-", depending on the format, as needed to capture all the relevant information from the transcript.)