Date: 1 November 2024
Length of session: 60 minutes
Session: Initial Consultation
**Client Introduction**
Client Overview: Sarah, [35 years old], does not have a formal diagnosis. She is not currently taking any medications. Sarah is seeking health coaching services to address her stress levels, improve her sleep quality, and develop healthier eating habits. She has previously tried various diets without long-term success and has attended mindfulness workshops.
Stage of Change Model Position: Sarah appears to be in the Contemplation stage, as she is aware of her issues and considering making changes but hasn't yet committed to a specific plan.
Care Team (if applicable): Dr. Emily Carter (Primary Care Physician)
The Focus of This Session Was: Establishing rapport, identifying Sarah's goals, and discussing the health coaching process.
**Tools and Education Used**
- What: Introduction to the Wheel of Life assessment tool and discussion of the importance of goal setting.
- How: The Wheel of Life was presented visually, and Sarah was guided through each area to assess her current satisfaction levels. Goal-setting principles were explained, and examples were provided.
- Confidence Rating: 7/10
- Relevance to Client Goals: The Wheel of Life helped Sarah identify areas of her life where she felt most and least satisfied, directly informing her goal-setting process. Goal setting is a key component of improving her eating habits, sleep quality and stress levels.
- Clinician Observations: Sarah actively engaged with the Wheel of Life, showing a willingness to self-reflect. She expressed some initial uncertainty about setting goals but seemed receptive to the process.
**Session Reflection**
- What Went Well: The Wheel of Life assessment was well-received and facilitated a productive discussion. Sarah was open and honest about her challenges.
- What Could Have Been Done Differently: More time could have been allocated to exploring specific goal-setting strategies.
- Key Learnings as a Health Coach: The importance of tailoring the initial session to the client's individual needs and pace.
**Action Plan Between Sessions:**
- Complete the Wheel of Life assessment.
- Identify 1-2 specific, measurable, achievable, relevant, and time-bound (SMART) goals related to sleep and stress.
- Research healthy recipes for the coming week.
Date:
[date of the session] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a date.)
Length of session:
[duration of the session] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a time duration.)
Session:
[session number or session type] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.)
**Client Introduction**
Client Overview:
[client's age, formal diagnosis if available, current medications, primary reasons for engagement with MHC services, and any previous attempts at addressing their concerns] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Stage of Change Model Position:
[client's current stage within the Transtheoretical Model as observed or discussed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Care Team (if applicable):
[details of involved care team members or healthcare professionals supporting the client] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of names and roles.)
The Focus of This Session Was:
[primary objective or topic addressed during the session] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
**Tools and Education Used**
- What: [tools, techniques, or educational materials used during the session] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as brief description.)
- How: [how tools or materials were applied or presented] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as brief description.)
- Confidence Rating: [client's self-reported confidence using the tool or education] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as numerical rating or descriptive phrase.)
- Relevance to Client Goals: [how the tool or education supported the client’s stated goals or desired outcomes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
- Clinician Observations: [observations regarding engagement or understanding when tools or education were introduced] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
**Session Reflection**
- What Went Well: [positive aspects, successes, or effective strategies in this session] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
- What Could Have Been Done Differently: [areas for improvement or alternative approaches] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
- Key Learnings as a Health Coach: [insights or professional development takeaways] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
**Action Plan Between Sessions:**
[specific steps, tasks, or commitments agreed upon by client and clinician] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of actionable items.)
(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.)