Clinical Interview:
Subjective
Presenting problem(s):
- The client presents with symptoms of anxiety and depression, which began approximately six months ago following a job loss. The client reports feeling overwhelmed, experiencing difficulty sleeping, and withdrawing from social activities. The client reports that the symptoms have been persistent and have worsened over the past month.
- The client reports feeling hopeless and experiencing frequent negative thoughts. The client is seeking support to manage their symptoms and improve their overall well-being.
History and Current Functioning:
- Mood: The client reports experiencing a depressed mood, with frequent feelings of sadness, hopelessness, and irritability. The client notes that these feelings are often triggered by thoughts about their job loss and financial concerns. The client reports using deep breathing exercises to cope with these feelings.
- Energy Levels: The client reports low energy levels throughout the day, feeling fatigued and lacking motivation. The client notes that these feelings are often worse in the morning.
- Sleep: The client reports difficulty falling asleep and staying asleep, with frequent awakenings during the night. The client reports feeling tired and unrested upon waking. The client reports using over-the-counter sleep aids occasionally.
- Employment/Education: The client is currently unemployed following a recent job loss. The client is actively seeking new employment opportunities.
- Family: The client reports a supportive relationship with their immediate family, but they also report feeling isolated from extended family members.
- Social: The client reports withdrawing from social activities and feeling isolated from their friends. The client reports a desire to reconnect with their social network.
- Exercise/Physical Activity: The client reports engaging in light exercise, such as walking, for approximately 30 minutes, three times per week.
- Eating Regime/Appetite: The client reports a decreased appetite and has lost some weight recently.
- Recreational/Interests: The client reports enjoying reading and listening to music, but has not been engaging in these activities as frequently due to their symptoms.
- Homework/Changes: The client reports feeling more anxious and depressed since the previous session. The client reports that this is related to increased financial stress.
- Previous Assessments & Interventions: The client has previously participated in individual therapy for six months, but discontinued due to financial constraints.
- Psychiatric History: The client has no prior psychiatric history.
- Physical Health: The client reports no significant physical health ailments.
- Current Medications: The client is not currently taking any medications.
- Supplements, Vitamins: The client is taking a daily multivitamin.
- Substance Use: The client reports no substance use.
- Developmental History: The client reports a normal developmental history.
- Relevant Cultural/Religious/Spiritual Issues: The client identifies as Christian and reports that their faith provides them with comfort and support.
- Forensic and Legal History: The client has no forensic or legal history.
Risk Assessment:
- Suicidal Ideation: The client reports passive suicidal ideation, but denies any active plans or intent.
- Self-harm: The client denies any history of self-harm.
Objective
Mental State Exam:
- Appearance: The client appears their stated age and is dressed in casual attire.
- Behaviour: The client is cooperative and engaged in the session.
- Speech: The client's speech is normal in rate and rhythm.
- Mood: The client's mood is depressed.
- Affect: The client's affect is constricted.
- Thought Process: The client's thought process is linear and goal-directed.
- Orientation: The client is oriented to time, place, and person.
- Memory: The client's memory is intact.
- Concentration: The client's concentration is intact.
- Judgement: The client's judgement appears intact.
- Insight: The client demonstrates some insight into their condition.
Assessment
Assessment, Clinical Formulation, and Findings:
- Worksheets, Assessments, Tests, Infosheets: The client completed the Beck Depression Inventory (BDI-II), which indicated moderate levels of depression.
- Art Therapy: The client was asked to create a self-portrait using various art supplies. The client used dark colours and expressed feelings of sadness and isolation through their artwork. The client reported feeling a sense of release and catharsis during the art-making process.
- Progress: The client has made some progress in identifying their triggers and developing coping mechanisms.
- Modalities: Cognitive Behavioral Therapy (CBT) techniques were used to challenge negative thoughts and promote positive self-talk. Art therapy was used to facilitate emotional expression and self-exploration.
- Predisposing Factors: The client's predisposing factors include a history of anxiety and a perfectionistic personality.
- Precipitating Factors: The client's precipitating factors include job loss and financial stress.
- Perpetuating Factors: The client's perpetuating factors include negative thought patterns and social isolation.
- Protecting Factors: The client's protecting factors include a supportive family and their faith.
Plan
Treatment Plan:
- Current Goals: The client will continue to work on identifying and challenging negative thoughts, developing coping mechanisms, and increasing social engagement.
- New Goals: The client will explore career options and develop a plan for financial stability.
- Homework: The client will complete a thought record daily and practice relaxation techniques.
- Referrals or Letters: The client will be referred to a career counsellor.
Date: 1 November 2024
Clinical Interview:
Subjective
Presenting problem(s):
- [Mention presenting problems - Onset, duration, course, severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
History and Current Functioning:
- Mood: [Describe current mood, including triggers, changes, coping mechanisms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Energy Levels: [Detail energy levels throughout the day, including triggers, changes, coping mechanisms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Sleep: [Detail sleep patterns including triggers, changes, coping mechanisms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Employment/Education: [Describe current employment or educational status, including triggers, changes, coping mechanisms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Family: [Detail family dynamics and relationships, including triggers, changes, coping mechanisms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Social: [Describe social interactions and support network, including triggers, changes, coping mechanisms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Exercise/Physical Activity: [Detail exercise routines or physical activities, including triggers, changes, coping mechanisms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Eating Regime/Appetite: [Describe eating habits and appetite, allergies, including triggers, changes, coping mechanisms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Recreational/Interests: [Mention hobbies or interests, including triggers, changes, coping mechanisms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Homework/Changes: [Mention any changes in mood, emotions, feelings, somatic changes since the previous session and what it is related to] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Previous Assessments & Interventions: [List any previous psychological assessments, therapies or interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Psychiatric History: [Detail any psychiatric history, including diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Physical Health: [Detail any physical health ailments and diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Current Medications: [List type, frequency, and daily dose] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Supplements, Vitamins: [List type, frequency, daily dose] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Substance Use: [Detail any substance use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Developmental History: [Detail developmental milestones and any issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Relevant Cultural/Religious/Spiritual Issues: [Mention any cultural, religious, or spiritual factors that are relevant] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Forensic and Legal History: [Detail any forensic or legal history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Risk Assessment:
- Suicidal Ideation: [History, attempts, plans] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Homicidal Ideation: [Describe any homicidal ideation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Self-harm: [Detail any history of self-harm] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Addictive Behaviours: [Detail any addictive behaviours, e.g., illicit drugs, gambling] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Risk-taking/Impulsivity: [Describe any risk-taking behaviors or impulsivity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Objective
Mental State Exam:
- Appearance: [Describe the patient's appearance] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Behaviour: [Describe the patient's behaviour] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Speech: [Detail speech patterns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Mood: [Describe the patient's mood] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Affect: [Describe the patient's affect] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Perception: [Detail any hallucinations or dissociations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Thought Process: [Describe the patient's thought process] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Thought Form: [Detail the form of thoughts, including any disorderly thoughts] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Orientation: [Detail orientation to time and place] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Memory: [Describe memory function] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Concentration: [Detail concentration levels] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Attention: [Describe attention span] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Judgement: [Detail judgement capabilities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Insight: [Describe the patient's insight into their condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment
Assessment, Clinical Formulation, and Findings:
- Worksheets, Assessments, Tests, Infosheets: [Mention any worksheets, infosheets, psychological assessments or tests conducted and their results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Art Therapy: [Describe the art therapy directive used and discussed, supplies and materials used, reasons for using said art therapy directive, any associations that come up in terms of memories, feelings, emotions, and benefits noted] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Progress: [Describe the client's progress since the last session] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Change or Addition of Goals: [Mention any new issues, goals, or concerns that have arisen] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Modalities: [Outline the interventions used during the session, including therapeutic techniques, modalities, and strategies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Predisposing Factors: [List predisposing factors to the patient's condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Precipitating Factors: [List precipitating factors that may have triggered the condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Perpetuating Factors: [List factors that are perpetuating the condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Protecting Factors: [List factors that protect the patient from worsening of the condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan
Treatment Plan:
- Current Goals: [Describe any current goals for treatment that will be continued] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- New Goals: [Describe any new goals for treatment to be considered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Homework: [Describe any homework or exercises assigned to the client] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Referrals or Letters: [Provide any referrals, recommendations, or letters for additional services or as requested] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(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.)
