Issue/Problem
- Difficulty with self-care tasks (Medium)
- Social isolation (High)
- Anxiety related to returning to work (Medium)
Framework formulation
Biological: Reports disrupted sleep patterns, decreased appetite, and fatigue.
Psychological: Experiences anxiety, low mood, and feelings of worthlessness.
Family/Whanau: Limited support from family, strained relationships.
School/Occupation: Currently on sick leave from work, concerns about returning.
Culture/Spirituality: No specific cultural or spiritual considerations mentioned.
Wider Social System: Limited access to community resources.
Predisposing: History of anxiety and previous episodes of depression.
Precipitating: Recent work-related stress and social isolation.
Perpetuating: Avoidance of social situations, negative self-talk.
Protective: Strong desire to return to work, previous coping strategies.
Age, Gender Identity, Living Arrangement: 35, Female, Living alone.
Personal Strengths/Qualities/Resources: Determined, resilient, and previously successful in her career.
Mental Health Concerns, including functional enquiry (sleep, appetite, motivation, concentration, attention). State Kessler score.: Reports difficulty sleeping, decreased appetite, low motivation, and difficulty concentrating. Kessler score: 25.
Presentation, (engagement, level of focus, motivation, interaction in session): Engaged in the session, but appeared anxious and hesitant at times. Motivation to return to work is high.
Conclusion: The client presents with significant anxiety and functional impairments related to her work and social life. Further assessment and intervention are required.
Possible ways to support or approaches to take with the young person and their family/whanau
- Cognitive Behavioural Therapy (CBT) to address anxiety and negative thought patterns.
- Graded exposure to social situations to reduce avoidance.
- Occupational therapy interventions to improve self-care skills and work-related tasks.
- Referral to a psychiatrist for medication review.
Personal Factors - Psychological: CBT, mindfulness techniques, and self-esteem building exercises.
Personal Factors - Biological: Sleep hygiene education, dietary advice, and medication review.
Contextual Factors - Family/Whanau: Family therapy to improve communication and support.
Contextual Factors - School/Occupation: Workplace assessment and return-to-work planning.
Contextual Factors - Wider Social System: Referral to community support groups and social activities.
Issue/Problem
List each issue/problem on a new line. You can indicate its priority as Low, Medium or High in brackets immediately after each statement
Framework formulation
Use the formulation framework to organise the information you have gathered about the client. Use short statements or lists (rather than long narrative) in the various sections of the framework. Please consider Biological, Psychological, Family/Whanau, School/Occupation, Culture/Spirituality and Wider Social System.
Predisposing
Precipitating
Perpetuating
Protective
[Age, Gender Identity, Living Arrangement] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Prior and/or Current Counselling or Agency Support] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Personal Strengths/Qualities/Resources] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Family and Relationships] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[School, Employment and Future Plans] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Social Wellbeing and Supports] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Interests] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Cultural Connection and Spirituality] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Mental Health Concerns, including functional enquiry (sleep, appetite, motivation, concentration, attention). State Kessler score.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Safety Concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Physical Health] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Presenting AOD Concerns, initiation (age of first use), pattern of use, amount, frequency (last four weeks including SACS score), risk taking (incl. binges, black outs, driving, crime and debt), family history, periods of abstinence / past attempts to reduce.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Presentation, (engagement, level of focus, motivation, interaction in session)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Conclusion] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Possible ways to support or approaches to take with the young person and their family/whanau
(List the support/approaches that are likely to have an impact on the difficulties the client is experiencing. There must be a clear link between the formulation and the possible support/approach you will offer)
Personal Factors - Psychological
Personal Factors - Biological
Contextual Factors - Family/Whanau
Contextual Factors - School/Occupation
Contextual Factors - Culture/Spirituality
Contextual Factors - Wider Social System
(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.)