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" [Date and time of the counselling session] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Client identifier or pseudonym] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Counsellor identifier or name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Was confidentiality, privacy and consent discussed with the student? [Details on whether confidentiality, privacy, and consent were discussed with the student, including any specific points of discussion or clarification.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Details of Consent [Specific details regarding the consent obtained from the student, including the scope of consent, any limitations, and confirmation of understanding.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Presenting Concern/s [Detailed description of the primary concerns presented by the student, encompassing their nature, duration, and any factors contributing to them.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Brief Relevant Background Details [Concise summary of relevant background information pertinent to the student's presenting concerns, including relevant personal history or previous experiences.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Description of the client's current support network, including individuals, groups, or resources available to them, and the nature of this support] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Mental State Examination (MSE): [Description of the client's general appearance, including their presentation, hygiene, and clothing] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Assessment of the client's behaviour and psychomotor activity, including any unusual movements or restlessness] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Evaluation of the client's mood (subjective emotional state) and affect (objective emotional expression), noting their congruence and range] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Description of the client's speech, including its rate, volume, tone, and coherence] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Assessment of the client's thought process (how thoughts are formed and organized), including any evidence of tangentiality, circumstantiality, or flight of ideas] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Summary of the content of the client's thoughts, including any preoccupations, delusions, or obsessions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Evaluation of the presence or absence of perceptual disturbances, such as hallucinations or illusions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Assessment of the client's orientation to person, place, and time] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Evaluation of the client's memory, including immediate, recent, and remote recall] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Assessment of the client's insight into their presenting issue and their understanding of its impact] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Evaluation of the client's judgment, including their ability to make sound decisions and understand the consequences of their actions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Agreed focus of the session [Description of the specific areas or topics that were mutually agreed upon by the student and clinician to be the main focus of the current session.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Outcome student wants from the session [The student's expressed desired outcome or goal for the current session, detailing what they hope to achieve or gain.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Risk Assessment and Management: [Identification and assessment of any current or historical risk factors, including but not limited to suicidal ideation, self-harm, harm to others, family violence, child protection concerns, or neglect, along with their severity and immediacy] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Specific actions taken or referrals made to mitigate identified risks, including safety planning, notification of relevant authorities, or liaison with other professionals] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Counselling Interventions and Discussion: [Summary of the solutions-focused CBT techniques and strategies discussed or applied during the session to address the presenting issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Key insights or understandings gained by the client during the session] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Client's expressed level of engagement and readiness for change] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Resources provided [Details of any resources, materials, or information provided to the student during or after the session.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Client Plan/Next Steps [Specific, measurable, achievable, relevant, and time-bound tasks or strategies agreed upon with the client to be implemented before the next session or as ongoing self-help] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Any resources or further information provided to the client] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Details of any scheduled future appointments or follow-up contact] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) (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, depending on the format, as needed to capture all the relevant information from the transcript.)