Reason for referral/what has brought the client here?
- The client was referred by their GP due to concerns about anxiety and difficulties managing emotions.
Hobbies, interests, and strengths
- Enjoys playing video games, drawing, and spending time with friends. Demonstrates strong artistic abilities.
Family
Name, occupation, relationship status, and level of contact with client:
Mother:
- Sarah Jones, Teacher, Married, High contact
Father:
- David Jones, Engineer, Married, High contact
Siblings (age and gender):
- Emily, 10, Female
Other family supports:
- Maternal grandparents are supportive and involved.
Additional notes:
- Client reports feeling overwhelmed by schoolwork and social pressures.
Presentation
Mini Mental Status Examination
Appearance and behaviour:
- Appears well-groomed and appropriately dressed. Behaviour is cooperative and slightly anxious.
Speech activity:
- Speech is clear and of normal rate and rhythm.
Mood:
- Reports feeling anxious and down.
Affect:
- Affect is congruent with reported mood; appears slightly constricted.
Cognition: oriented? Y / N ; memory impairment? Short / long ; attention?
- Oriented to person, place, and time. No apparent memory impairment. Attention appears intact.
Thoughts: suicidality? Ideation / plan / intent / self-harm ; homicidality ;
- Denies suicidal ideation, plan, or intent. Denies homicidal ideation.
Delusions? Grandiose / paranoid / religious / other
- Denies delusions.
Perception: hallucinations? Auditory / visual ; depersonalisation / derealisation
- Denies hallucinations, depersonalisation, or derealisation.
Behaviour: cooperative / guarded / hyperactive / agitated / aggressive / withdrawn / other
- Cooperative.
Insight: good / fair / poor
- Fair insight into their difficulties.
Judgement: good / fair / poor
- Good judgement.
Presenting Problem
(e.g., parent/carer and client's perspectives and areas of concern)
- Client reports feeling anxious, particularly in social situations and at school. They also report difficulty managing feelings of sadness and frustration.
Onset of presenting problem
- Symptoms began approximately six months ago, coinciding with increased academic pressure.
Goals in therapy
(e.g., what would client like to achieve during therapy?)
1. Reduce anxiety in social situations.
2. Develop coping mechanisms for managing difficult emotions.
3. Improve self-esteem.
Current functioning
Sleep
(e.g., does client fall asleep easily? Stay asleep through the night? Any nightmares?)
- Reports difficulty falling asleep due to racing thoughts. Wakes up occasionally during the night.
Appetite/diet
(e.g., recent loss/gain of weight? Does client eat school lunches? Body image? Fussy eater? What are client’s preferred food? Any therapist support? Dietician? Review by GP/other doctor?)
- Appetite is variable. Eats school lunches. No concerns about body image.
Developmental History
Pregnancy
- Mother reported an uncomplicated pregnancy.
Birth
- Normal vaginal delivery.
Early years
Sleep:
- Regular sleep patterns as a young child.
Feeding:
- Breastfed for six months.
Attachment:
- Secure attachment to parents.
Developmental milestones
Walking:
- Walked at 12 months.
Talking milestone:
- Spoke in full sentences by 3 years.
Toileting milestone:
- Toilet trained by age 3.
Sensory sensitivities/interests
(e.g., textures, noise, smells)
- Sensitive to loud noises.
Social History
Current social functioning
Friends:
- Has several close friends.
Support network:
- Strong support from family and friends.
Safe people:
- Parents, grandparents, and close friends.
Bullying?:
- Denies any bullying experiences.
Peers and teachers?:
- Positive relationships with peers and teachers.
Other relationships?:
- No other significant relationships.
History of abuse, losses, separations, significant life changes?
- No history of abuse, losses, separations, or significant life changes.
Violence (past/present)
- No history of violence.
Education History
Name of school and grade
- Maplewood Elementary, Grade 5
Missed any days of school in the past 2 weeks?
- Missed one day of school due to feeling unwell.
Current academic performance
- Performing well academically.
Any learning difficulties/concerns at school?
Reading:
- No reading difficulties.
Spelling:
- No spelling difficulties.
Maths:
- No maths difficulties.
Other subjects:
- No difficulties in other subjects.
Speech/Language:
- No speech/language difficulties.
Attention:
- No attention difficulties.
Behaviour:
- No behaviour difficulties.
Co-ordination:
- No co-ordination difficulties.
Current supports at school
- Receives classroom support from the teacher.
Psychiatric/Psychological and Medical History
Diagnoses or traits/symptoms
- Diagnosed with Generalized Anxiety Disorder.
Previous therapy
- No previous therapy.
Suicidality (past/present)/NSSI
- Denies suicidality and non-suicidal self-injury.
Risks to others
- No risks to others.
Safety plan required?
Yes
No
If yes, was a safety plan created/reviewed?
Yes
No
If yes; Safety plan overview
- N/A
Medical history
- No significant medical history.
Family medical history
- Mother has a history of anxiety.
Forensic & Legal History
Any current or pending legal or court cases:
Denied
Yes (discuss referral options)
- Denied.
Previous juvenile offenses:
Denied
Yes
If yes, provide details & outcomes
- Denied.
Past/Present school-related issues:
Denied
Yes
If yes, provide details & outcomes
- Denied.
Child Protection Services involvement:
Denied
Yes
If yes, details & circumstances of any ongoing involvement
- Denied.
Formulation
Predisposing factors
- Family history of anxiety.
Precipitating factors
- Increased academic pressure and social demands.
Perpetuating factors
- Avoidance of social situations.
Protective factors
- Strong family support and good coping skills.
Plan
(e.g., initial thoughts/direction, where to go from here?)
- Begin Cognitive Behavioral Therapy (CBT) to address anxiety symptoms. Psychoeducation for the client and parents. Schedule weekly sessions. Review progress in four weeks. Next appointment 1 November 2024.
Reason for referral/what has brought the client here?
- [describe reason for referral or what has brought the client here] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Hobbies, interests, and strengths
- [describe hobbies, interests, and strengths] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Family
Name, occupation, relationship status, and level of contact with client:
Mother:
- [name, occupation, relationship status, and level of contact with client] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Father:
- [name, occupation, relationship status, and level of contact with client] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Siblings (age and gender):
- [age and gender of siblings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Other family supports:
- [describe other family supports] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Additional notes:
- [additional notes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Presentation
Mini Mental Status Examination
Appearance and behaviour:
- [describe appearance and behaviour] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Speech activity:
- [describe speech activity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Mood:
- [describe mood] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Affect:
- [describe affect] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Cognition: oriented? Y / N ; memory impairment? Short / long ; attention?
- [describe cognition, orientation, memory impairment, and attention] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Thoughts: suicidality? Ideation / plan / intent / self-harm ; homicidality ;
- [describe thoughts, suicidality, and homicidality] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Delusions? Grandiose / paranoid / religious / other
- [describe delusions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Perception: hallucinations? Auditory / visual ; depersonalisation / derealisation
- [describe perception, hallucinations, depersonalisation, and derealisation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Behaviour: cooperative / guarded / hyperactive / agitated / aggressive / withdrawn / other
- [describe behaviour] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Insight: good / fair / poor
- [describe insight] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Judgement: good / fair / poor
- [describe judgement] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Presenting Problem
(e.g., parent/carer and client's perspectives and areas of concern)
- [describe presenting problem] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Onset of presenting problem
- [describe onset of presenting problem] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Goals in therapy
(e.g., what would client like to achieve during therapy?)
1. [goal 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
2. [goal 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
3. [goal 3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Current functioning
Sleep
(e.g., does client fall asleep easily? Stay asleep through the night? Any nightmares?)
- [describe sleep patterns and issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Appetite/diet
(e.g., recent loss/gain of weight? Does client eat school lunches? Body image? Fussy eater? What are client’s preferred food? Any therapist support? Dietician? Review by GP/other doctor?)
- [describe appetite and diet] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Developmental History
Pregnancy
- [describe pregnancy details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Birth
- [describe birth details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Early years
Sleep:
- [describe early years sleep patterns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Feeding:
- [describe early years feeding patterns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Attachment:
- [describe early years attachment patterns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Developmental milestones
Walking:
- [describe walking milestone] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Talking milestone:
- [describe talking milestone] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Toileting milestone:
- [describe toileting milestone] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Sensory sensitivities/interests
(e.g., textures, noise, smells)
- [describe sensory sensitivities and interests] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Social History
Current social functioning
Friends:
- [describe current social functioning with friends] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Support network:
- [describe support network] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Safe people:
- [describe safe people] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Bullying?:
- [describe bullying experiences] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Peers and teachers?:
- [describe relationships with peers and teachers] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Other relationships?:
- [describe other relationships] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
History of abuse, losses, separations, significant life changes?
- [describe history of abuse, losses, separations, significant life changes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Violence (past/present)
- [describe history of violence] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Education History
Name of school and grade
- [name of school and grade] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Missed any days of school in the past 2 weeks?
- [describe any missed days of school in the past 2 weeks] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Current academic performance
- [describe current academic performance] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Any learning difficulties/concerns at school?
Reading:
- [describe reading difficulties/concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Spelling:
- [describe spelling difficulties/concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Maths:
- [describe maths difficulties/concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Other subjects:
- [describe other subjects difficulties/concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Speech/Language:
- [describe speech/language difficulties/concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Attention:
- [describe attention difficulties/concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Behaviour:
- [describe behaviour difficulties/concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Co-ordination:
- [describe co-ordination difficulties/concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Current supports at school
- [describe current supports at school] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Psychiatric/Psychological and Medical History
Diagnoses or traits/symptoms
- [describe diagnoses or traits/symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Previous therapy
- [describe previous therapy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Suicidality (past/present)/NSSI
- [describe suicidality and non-suicidal self-injury] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Risks to others
- [describe risks to others] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Safety plan required?
Yes
No
If yes, was a safety plan created/reviewed?
Yes
No
If yes; Safety plan overview
- [describe safety plan overview] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Medical history
- [describe medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Family medical history
- [describe family medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Forensic & Legal History
Any current or pending legal or court cases:
Denied
Yes (discuss referral options)
- [describe current or pending legal or court cases] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Previous juvenile offenses:
Denied
Yes
If yes, provide details & outcomes
- [describe previous juvenile offenses and outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Past/Present school-related issues:
Denied
Yes
If yes, provide details & outcomes
- [describe past/present school-related issues and outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Child Protection Services involvement:
Denied
Yes
If yes, details & circumstances of any ongoing involvement
- [describe Child Protection Services involvement and circumstances] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Formulation
Predisposing factors
- [describe predisposing factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Precipitating factors
- [describe precipitating factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Perpetuating factors
- [describe perpetuating factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Protective factors
- [describe protective factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Plan
(e.g., initial thoughts/direction, where to go from here?)
- [describe plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
(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 include 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, depending on the format, as needed to capture all the relevant information from the transcript.)
