Review Since Last Session:
- Summary of the child client’s current presentation and how things have been since the last appointment. Including anything relevant from the parent/caregiver.
Past Medical & Psychiatric History:
- Psychiatric Diagnoses.
- Medical History.
- Current Medications.
Session Content:
- Relevant discussions about life circumstances, milestones, friendships, other relationships, interactions, or events important to the child client’s wellbeing.
- Discussion about any goals, including new objectives or review of existing goals.
- Discussion about any setbacks or obstacles to progress for therapy goals and objectives.
- Any clinician comments about how session content revealed something about the child’s inner world, including comments about non-verbal behaviours and body language.
- Level of rapport and engagement throughout the session, including any changes and what led to them.
Interventions:
- Details of specific therapeutic techniques and interventions used or to be used (e.g., sand tray, art, play, games, etc.) and techniques modified for use with children (e.g., simplified concepts, use of metaphors, stories, or characters).
- Ideas, concepts, or frameworks introduced, or the content of any handouts, use of whiteboard, or other visual aids or resources.
Key Discussions with Parent/Caregiver:
- Important discussion points between the therapist and parent/caregiver.
Risk Assessment and Management:
- Suicidal Ideation.
- Homicidal Ideation.
- Self-harm.
- Violence & Aggression.
- Addictive Behaviours.
- Risk-taking/Impulsivity.
- Risk Management Plan.
Next Steps:
- Date and time of next session and any plans.
- Tasks or activities assigned to the child or parent/caregiver, and any tasks the therapist will complete (e.g., follow up with parent, caregiver, or teacher).
Review Since Last Session:
- Lily presented as slightly more settled than previous sessions. Mum (Mary Blogs) reported that Lily had a “better week” with fewer meltdowns at home, though she still had two difficult mornings before school.
- Severity/Impact: Lily’s anxiety continues to affect her school attendance, with two late arrivals this fortnight due to separation distress at drop-off.
Past Medical & Psychiatric History:
- Psychiatric Diagnoses: Generalised Anxiety Disorder (diagnosed by Dr Sarah Green, Paediatrician, March 2025).
- Current Medications: Nil.
Session Content:
- Lily spoke about an upcoming school camp and expressed worry about sleeping away from home; she also shared that she had played with a new friend at lunch this week, which she seemed pleased about.
- Existing goals were reviewed, including increasing Lily’s ability to use coping strategies independently when feeling worried at school.
- Lily reported that she “forgot” to use her calm-down plan during a worry episode at school, identifying remembering to use strategies in the moment as an ongoing obstacle.
- The clinician noted that Lily’s play with the worry dolls suggested a preoccupation with themes of safety and being away from her parents. Lily was observed to become physically tense and fidgety when discussing school camp.
- Rapport was strong throughout the session; Lily was engaged and talkative, though she became quieter and less responsive when the conversation shifted to school camp.
Interventions:
- A worry scaling activity was used, where Lily rated her worries on a “worry thermometer” (visual scale from 0–10) to help her differentiate between small, medium, and big worries. Lily and the therapist practised slow breathing using the “smell the flower, blow out the candle” technique.
- The concept of “brave steps” (graded exposure) was introduced using a staircase drawing on the whiteboard, with each step representing a small goal leading up to school camp.
Key Discussions with Parent/Caregiver:
- Mum was brought in for the final 10 minutes. The therapist discussed strategies for supporting Lily with school drop-off, including keeping farewells brief and consistent. The therapist and Mum agreed to begin planning small practice separations (e.g., a sleepover at Grandma’s house) in preparation for school camp.
Risk Assessment and Management:
- Violence & Aggression: Mum reported that Lily had one episode of hitting her younger brother during a meltdown this week; this was situational and not directed or sustained.
Next Steps:
- Next Session: Tuesday 5 August 2025 at 3:30 PM. The session will focus on building the brave steps hierarchy for school camp.
- Assigned Homework: Lily to practise the “smell the flower, blow out the candle” breathing at least once per day, using a sticker chart provided. Mum to arrange one practice separation before next session. Therapist to email Lily’s school counsellor (with Mum’s consent) to coordinate drop-off support.
