Mode of delivery: In-person
Location: Home
Consent form completed: Yes
AI consent: Yes
Referral: Self-referred
General introduction and history: The client, [insert age] years old, presents with a history of moderate depression and anxiety, exacerbated by recent job loss. She reports feeling overwhelmed and struggling to cope with daily tasks.
Mental Status Examination:
Appearance: Appears her stated age, well-groomed, and dressed appropriately.
Behaviour: Cooperative and engaged during the session.
Speech: Normal rate and rhythm, with no significant abnormalities.
Language: Fluent and coherent.
Mood and Affect: Reports low mood and anxious affect, congruent with her reported experiences.
Thought Content: Reports negative self-talk and worry about the future.
Perception: No reported hallucinations or delusions.
Cognition: Oriented to person, place, and time. Memory intact.
Insight and Judgement: Demonstrates some insight into her difficulties and acknowledges the need for support. Judgement appears intact.
Session content: The session focused on exploring the client's current stressors, identifying coping mechanisms, and developing a plan for managing her symptoms.
Biological/Medical/Physical issues: Reports difficulty sleeping and decreased appetite.
Psychological Issues: Symptoms
* Depression
* Anxiety
Current Stressors:
* Job loss
* Financial concerns
* Relationship difficulties
Other:
Family history/structure: Client is single, with no children. She has a supportive relationship with her parents.
Family history of mental health issues: Mother has a history of anxiety.
Relationship status: Single
Occupation: Unemployed
Financial situation / Income: Limited income, experiencing financial stress.
Sports / Exercise: Walks for 30 minutes, three times a week.
Interests / Hobbies / other activities: Enjoys reading and spending time in nature.
Social: Has a small circle of close friends.
Sexuality: Heterosexual
Religion: Non-religious
Psychiatric History: Previously diagnosed with depression and anxiety. Has tried medication in the past.
Sleep: Average 6 hours of sleep. Reports onset insomnia.
Appetite: Decreased appetite.
Substances: No use of drugs or tobacco. Drinks alcohol occasionally.
Medications: Currently not taking any psychiatric medications.
Trauma / Abuse / Loss / Neglect: No reported history of trauma or abuse.
Previous Self-harm / suicide attempt: No history of self-harm or suicide attempts.
Current Self-harm / suicidal ideation: No current suicidal ideation.
Future Orientation: Expresses a desire to find a new job and improve her mental health.
Overall Risk:
* Future oriented
* Adequately supported
* No recent suicidal ideation
Safety Plan: Client has identified her mother as someone she can contact if feeling overwhelmed.
Case Formulation:
Pre-disposing Factors:
* Psychological: History of anxiety and depression.
Precipitating Factors:
* Social: Job loss and financial stressors.
Perpetuating Factors:
* Psychological: Negative self-talk and maladaptive coping mechanisms.
Protective Factors:
* Psychological: Resilience and willingness to seek help.
* Social: Supportive family and friends.
Supports:
* Mother
* Friends
Triggers:
* Financial stress
* Social isolation
Current coping strategies:
* Spending time with friends
* Reading
* Walking
Overall Impression: The client presents with moderate depression and anxiety, exacerbated by recent stressors. She demonstrates resilience and a willingness to engage in therapy. Treatment goals include symptom management, coping skill development, and addressing underlying issues.
Current signs / symptoms:
Depression:
* Low Mood
* Loss of interest in activities
* Sleep Disruption
* Low Energy
* Feeling Worthless
* Diminished Concentration
Anxiety:
* Excessive Worry most days
* Difficulty Concentrating
* Sleep Disturbance
Diagnosis: Psychologist diagnosis: Major Depressive Disorder, Generalized Anxiety Disorder
ICD-11: 6A80, 6B00
DSM-5: 296.2x, 300.02
Interventions:
* Psychoeducation about depression and anxiety.
* Exploration of coping mechanisms.
* Cognitive restructuring techniques.
Plan:
* Cognitive Behavioural Therapy
Client Treatment Goals:
* Reduce symptoms of depression and anxiety.
* Develop effective coping strategies.
* Improve mood and overall well-being.
Homework:
* Practice relaxation techniques daily.
* Keep a mood journal.
* Identify and challenge negative thoughts.
Further Appointments: 1 week
Follow up:
* Review progress on treatment goals.
* Assess for any changes in symptoms.
* Adjust treatment plan as needed.
Date: 1 November 2024
