Current Presentation:
- Child’s current presentation or presenting complaint, including how long the issue(s) have been occurring.
- Current impact of the child client’s difficulties and symptoms on their functioning (e.g., impact on school, friendships, activities of daily life).
Past Medical & Psychiatric History:
- Psychiatric Diagnoses.
- Medical History.
- Treatments / Hospitalisations.
- Current Medications.
Mental Status Examination:
- Behaviour: e.g., activity level, interaction with surroundings, attention span, observed regulation behaviours, energy levels, and any boundary-setting or limit-testing behaviours that occurred.
- Speech: e.g., rate, volume, quantity, tone, and rhythm of speech.
- Mood: self-described emotional state.
- Affect: range and appropriateness of emotional responses.
- Thoughts: thought process and thought content, noting any distortions, delusions, or preoccupations.
- Perceptions: hallucinations or sensory misinterpretations.
- Cognition: e.g., memory, orientation to time/place/person, concentration, and comprehension.
- Insight: understanding of own condition and symptoms, noting any lack of awareness or denial.
- Judgment: decision-making ability and understanding of the consequences of their actions.
Session Content:
- Discussions and interactions with the child client during the session.
- Life events, milestones, or circumstances that have occurred or are upcoming for the child client.
- Friendships, key relationships, or interactions, including names of people mentioned, and current social functioning.
- Clinician comments about how session content revealed something about the child’s inner world e.g., non-verbal behaviours and body language.
- Level of rapport and engagement.
Goals:
- Summary of goals, including new objectives, desires, or things to work on, or if existing goals were reviewed.
Obstacles, Setbacks and Progress:
- Child’s progress towards each therapy goal/objective.
- Setbacks and obstacles to progress for each therapy goal/objective.
Interventions:
- Specific therapeutic techniques and interventions used or to be used, including techniques regularly used with children (e.g., sand tray, art, play, games) and techniques modified for use with children (e.g., simplified concepts, use of metaphors, stories, or characters).
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.
Session Summary:
Summary of the child’s progress with emphasis on current status, risk assessment and management, interventions, progress towards achieving therapy goals/objectives, setbacks, and obstacles.
Next Steps:
- Next Session: date and time, including any plans.
- Assigned Homework: 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).
Current Presentation:
- Lily is a nine-year-old girl who was referred by her school counsellor for anxiety-related difficulties, including persistent worry, separation anxiety from her mother (Mary Bloggs), and somatic complaints (stomachaches) that have been occurring for approximately five months. Mary was present for the first 10 minutes and final 5 minutes of the session.
- Severity/Impact: Lily’s anxiety continues to impact her school attendance, with Mary reporting that Lily has missed four days of school in the past fortnight due to morning distress and complaints of feeling sick. Lily also described difficulty joining in at lunchtime, stating she “just sits near the teacher” rather than playing with peers.
Past Medical & Psychiatric History:
- Psychiatric Diagnoses: Generalised Anxiety Disorder (diagnosed by Dr Sarah Taylor, Paediatrician, August 2025).
- Current Medications: Nil.
Mental Status Examination:
- Behaviour: Lily presented as initially quiet and reserved, sitting close to her mother and avoiding eye contact with the therapist. Following Mary’s departure from the room, Lily gradually engaged with the play materials, selecting figurines from the sand tray. Her activity level increased over the session. Lily tested a boundary by attempting to take a figurine home, which was gently addressed by the therapist.
- Mood: When asked how she was feeling using the feelings thermometer, Lily pointed to “a bit worried” and stated, “My tummy feels funny again.”
- Affect: Lily’s affect was initially constricted and anxious but broadened as the session progressed. She smiled and laughed briefly during sand tray play. Affect was congruent with stated mood.
- Thoughts: Lily’s thought content was notable for preoccupation with her mother’s wellbeing, repeatedly asking if her mum was “still in the waiting room.” No delusional thinking was observed. Lily referenced her imaginary friend “Sparkle the unicorn,” who she described as someone who “helps me when I’m scared at night.” This is considered consistent with her developmental stage and may serve a self-soothing function.
- Cognition: Lily was oriented to person and place. Concentration was somewhat variable; she was more focused during sand tray play than during verbal discussion.
- Insight: Lily demonstrated emerging insight, acknowledging that her “tummy feelings” happen most when she has to leave her mum, though she struggled to articulate this further.
- Judgment: Age-appropriate. Lily was able to identify that asking for help from her teacher when feeling worried at school was a helpful strategy.
Session Content:
- Lily discussed an upcoming school camp scheduled for next term, expressing significant worry about being away from home overnight. She stated, “What if something bad happens to Mum while I’m gone?” The therapist explored this worry using child-friendly Socratic questioning.
- Lily mentioned her friend “Sophie” and shared that they used to play together at lunch, but Sophie now plays with a different group. Lily described feeling “left out” and said she mostly spends lunchtimes near the teacher on duty. She did not report any conflict with peers.
- The therapist noted that during sand tray play, Lily placed a small animal figure alone inside a fenced area while larger figures were grouped together outside. The therapist commented that this arrangement may reflect Lily’s sense of isolation and her feelings of being separated from others.
- Rapport was initially limited due to Lily’s anxiety at the start of the session. Engagement improved markedly once play-based activities were introduced, and Lily was animated and talkative during the sand tray activity.
Goals:
- Existing therapy goals were reviewed: (1) reduce separation anxiety symptoms to enable consistent school attendance, and (2) build Lily’s confidence in social situations with peers. A new goal was discussed with Mary: (3) prepare Lily for the upcoming school camp by gradually building her tolerance of time away from home.
- The therapist suggested Lily practise her “brave breathing” (four-count breathing technique) each morning before school and at bedtime. Lily agreed to try this and said Sparkle the unicorn could remind her.
Obstacles, Setbacks and Progress:
- Lily has made some progress towards her first goal, with Mary reporting that two of the four school days missed were half-days rather than full absences, representing an improvement from the previous fortnight when all absences were full days. Lily was also able to separate from Mary during today’s session with less distress than in session five.
- Setbacks include the increased worry triggered by the upcoming school camp announcement, which has temporarily heightened Lily’s separation anxiety symptoms. The change in her friendship with Sophie also appears to be contributing to reluctance around attending school.
Interventions:
- Sand tray therapy was used as the primary intervention this session, allowing Lily to express her emotional experiences non-verbally. The therapist used reflective commentary to gently name themes observed in the sand tray (e.g., “It looks like that little animal might be feeling a bit alone”).
- The therapist introduced a simplified cognitive-behavioural framework using “thought bubbles” drawn on a whiteboard. The therapist drew a picture of a girl with a thought bubble containing “Something bad will happen to Mum” and an empty thought bubble, then asked Lily to help fill in a “braver thought.” Lily suggested, “Mum will be there when I get home.”
- The “brave breathing” technique (four-count box breathing adapted for children) was reviewed and practised together using a pinwheel to make the exercise concrete and engaging.
Key Discussions with Parent/Caregiver:
- Mary was brought in for the final five minutes. The therapist discussed strategies for supporting Lily with school drop-off, including keeping farewells brief and consistent. The therapist and Mary agreed to begin planning small practice separations (e.g., Lily staying with her grandmother for one to two hours on the weekend) in preparation for school camp. Mary expressed concern about whether Lily should attend camp; the therapist suggested this be a collaborative decision made over the coming weeks as Lily builds her coping skills.
Risk Assessment and Management:
- Violence & Aggression: Mary noted that Lily has had occasional outbursts of crying and mild tantrums when forced to attend school, but no aggression towards others.
Session Summary:
Lily presented with ongoing separation anxiety and social withdrawal, both of which continue to impact her school attendance and peer relationships. She engaged well with sand tray therapy and was able to participate in a simplified cognitive restructuring exercise. Emerging insight was observed regarding the link between her somatic symptoms and anxiety about separating from her mother. Progress towards therapy goals is gradual; Lily’s capacity to separate from Mary during sessions is improving, though the upcoming school camp has introduced a new source of anxiety. No significant risk concerns were identified. The therapeutic relationship continues to strengthen, particularly through play-based engagement.
Next Steps:
- Next Session: Wednesday 25 February 2026 at 3:30 PM. The session will focus on continuing sand tray work and beginning a graded exposure hierarchy for separation-related situations, including preparation for school camp.
- Assigned Homework: Lily to practise “brave breathing” each morning and at bedtime. Mary to trial one planned short separation over the weekend and report back on how Lily managed. Therapist to contact Lily’s school counsellor (with Mary’s consent) to discuss classroom-based supports for Lily’s social engagement at lunchtime.
