Single Session (SSn) case note

Single Session (SSn) Case Note Session Details: client has consented to use AI clinical notation tool Heidi, clinician has provided client with information sheet on how Heidi handles and uses client information and client has been able to discuss any questions or concerns they have. Notes generated by Heidi and reviewed by clinician at the end of session 1 November 2024, 10:00 AM - 11:00 AM Client Identifier: CS001 Counsellor: Dr. Sarah Jenkins Was confidentiality, privacy and consent discussed with the student? Yes, confidentiality, privacy, and consent were thoroughly discussed. The client confirmed understanding of the limits to confidentiality, particularly regarding self-harm or harm to others, and understood how their personal information would be stored and used. Details of Consent Consent was obtained for the single session of counselling, with the understanding that information shared would be used solely for the purpose of therapeutic support and documentation, and that anonymised data might be used for service improvement. The client explicitly consented to the use of the AI clinical notation tool, Heidi, after reviewing the information sheet and having all questions answered. Presenting Concern/s The client, a 22-year-old university student, presented with significant academic stress and anxiety related to upcoming final exams. They reported difficulty concentrating, persistent worry about failing, and experiencing panic attacks in the week leading up to the session. These symptoms have been present for approximately three weeks, intensifying recently, and are impacting their sleep and appetite. They expressed feeling overwhelmed and isolated. Brief Relevant Background Details The client has no previous history of mental health support. They are an international student, living away from their family for the first time. They reported a generally good relationship with their family but feels unable to burden them with their current struggles. There is no family history of significant mental health issues. The client maintains a part-time job alongside their studies, which adds to their time pressures. Client's current support network includes a few close friends at university with whom they occasionally socialise. They also connect with their family via video calls bi-weekly. There is no formal support network currently in place. Mental State Examination (MSE): General appearance: The client was neatly dressed in casual attire, appeared slightly fatigued with mild dark circles under their eyes. Good personal hygiene. Behaviour and psychomotor activity: Client was cooperative, maintaining good eye contact throughout the session. Fidgeted occasionally with their hands but no overt psychomotor agitation or retardation observed. Mood and affect: Mood was reported as 'anxious' and 'stressed'. Affect was congruent with mood, showing a restricted range, appearing tense and worried. No lability. Speech: Speech was of normal rate and volume, clear articulation. No pressure of speech or poverty of speech noted. Thought process: Thought process was logical and coherent, goal-directed. No evidence of tangentiality, circumstantiality, or flight of ideas. Content of thoughts: Preoccupied with academic performance and fear of failure. No delusions, obsessions, or suicidal ideation reported. Perceptual disturbances: No hallucinations or illusions reported. Orientation: Fully oriented to person, place, and time. Memory: Intact for immediate, recent, and remote recall. Insight: Good insight into their current anxiety being linked to academic pressure and understanding its impact on their daily functioning. Judgment: Good judgment demonstrated in seeking support for their difficulties. Agreed focus of the session The agreed focus was to develop immediate coping strategies for managing exam-related anxiety and to explore realistic academic expectations. Outcome student wants from the session The client expressed a desire to leave the session with practical tools to reduce their anxiety and a clearer plan for how to approach their studies in the coming weeks. Risk Assessment and Management: No current suicidal ideation, self-harm, or harm to others reported. No family violence or child protection concerns identified. Client denied any past history of self-harm or suicidal thoughts. Risk of increased anxiety and potential academic underperformance due to stress acknowledged. Safety planning focused on self-care strategies and identification of trusted individuals to contact in crisis. No referrals to external authorities were necessary at this time. Counselling Interventions and Discussion: Utilised solution-focused CBT techniques, including identifying current strengths and past successes in managing stress. Explored cognitive distortions related to 'catastrophising' exam outcomes and introduced reframing techniques. Discussed practical anxiety management strategies such as deep breathing exercises, progressive muscle relaxation, and time management tips for studying. Explored the 'miracle question' to help the client envision a future without this anxiety. Key insights gained by the client included the realisation that their self-worth is not solely tied to academic success and that seeking help is a sign of strength, not weakness. They also understood the importance of breaking down large tasks into smaller, manageable steps. Client's expressed level of engagement was high, demonstrating readiness for change and actively participating in discussions and exercises. Resources provided A handout on anxiety management techniques (deep breathing, progressive muscle relaxation), a link to university's academic support services for study skills, and information on healthy sleep hygiene. Client Plan/Next Steps 1. Practice deep breathing exercises for 5-10 minutes twice daily. 2. Dedicate specific, timed blocks for studying, including short breaks, rather than continuous prolonged periods. 3. Identify one non-academic enjoyable activity to engage in each day for stress relief. 4. Contact a friend if anxiety levels become overwhelming. 5. Review the university's academic support services website for time management workshops. Resources provided: Handout on anxiety management, link to university academic support services. No further appointment scheduled at this time, however, the client was encouraged to re-book if symptoms persist or worsen after implementing the strategies. Accredited Mental Health Social Worker