Current Presentation
- Describe client’s presenting concerns and how long issues have been occurring.
- Severity/Impact: Describe impact on functioning (e.g., work, school, daily activities).
Past Medical & Psychiatric History
- Psychiatric Diagnoses: Record any psychiatric diagnoses.
- Medical History: Record any relevant medical issues.
- Treatments / Hospitalisations: Note any recent treatments or hospitalisations.
- Current Medications: List current medications, including dose and frequency.
- Recent Substance Use: Record details of recent substance use.
Mental Status Examination
- Behaviour: Describe client’s activity level and notable behaviours.
- Speech: Comment if speech was unusually fast or slow.
- Mood: Record client’s reported emotional state.
- Affect: Describe client’s emotional expression and range.
- Thoughts: Note thought processes and content, including any abnormalities.
- Perceptions: Record any hallucinations or sensory issues.
- Cognition: Describe memory, orientation, concentration, comprehension.
- Insight: Comment on client’s understanding of their condition.
- Judgment: Describe client’s decision-making ability.
Session Content
- Summarise other discussions from the session.
- Note any life events, milestones, or upcoming changes.
- Record key relationships mentioned.
Goals
- Summarise any new, reviewed, or ongoing goals discussed.
- Record tasks or activities planned between sessions.
Obstacles, Setbacks and Progress
- Describe progress towards goals.
- Describe setbacks or obstacles encountered.
Interventions
- Summarise therapeutic techniques or interventions used.
- Note any concepts, frameworks, handouts or resources discussed.
Risk Assessment and Management
- Suicidal Ideation: Record any suicidal thoughts or behaviours.
- Homicidal Ideation: Record any homicidal thoughts or behaviours.
- Self-harm: Record any self-harming behaviour.
- Violence & Aggression: Note any incidents of violence or aggression.
- Addictive Behaviours: Record any addictive behaviours.
- Risk-taking/Impulsivity: Describe any risk-taking or impulsivity.
- Management Plan: Summarise risk management strategies.
Session Summary
- Summarise progress, risks, interventions, setbacks, and overall session outcomes.
Next Steps
- Next Session: Note the date, time, and plan for the next session.
- Assigned Homework: Record any homework or tasks assigned.
Current Presentation
- Client presented reporting ongoing feelings of anxiety related to work stress, which have been building over the past two months.
- Severity/Impact: Anxiety is affecting concentration at work and sleep quality, leading to reduced productivity and fatigue.
Past Medical & Psychiatric History
- Psychiatric Diagnoses: Generalised Anxiety Disorder (diagnosed 2022).
- Medical History: No significant medical issues reported.
- Treatments / Hospitalisations: Completed a 12-week CBT program in 2022; no psychiatric hospitalisations.
- Current Medications: None currently.
- Recent Substance Use: Reports occasional alcohol use (2–3 standard drinks per week).
Mental Status Examination
- Behaviour: Alert, cooperative, maintained good eye contact.
- Speech: Normal pace and volume.
- Mood: “Overwhelmed and exhausted.”
- Affect: Restricted range, congruent with reported mood.
- Thoughts: No evidence of disordered thinking; recurrent worries about work performance noted.
- Perceptions: No hallucinations or perceptual disturbances reported.
- Cognition: Oriented to time, place, and person; concentration mildly impaired when discussing work-related topics.
- Insight: Demonstrates good insight into symptoms and their impact.
- Judgment: Sound judgment; no concerns noted.
Session Content
- Discussed ongoing work stressors, including increased workload and recent changes in management structure.
- Client reported struggling with sleep due to racing thoughts about work deadlines.
- Explored coping strategies currently being used, including exercise and mindfulness, but noted inconsistency.
- Discussed upcoming annual review meeting causing additional anxiety.
- Identified the client’s support network, including supportive partner and close friend.
Goals
- Refine and implement a consistent daily mindfulness practice.
- Prepare structured talking points for upcoming work review to reduce anticipatory anxiety.
- Improve sleep hygiene by setting a regular bedtime and reducing screen time.
Obstacles, Setbacks and Progress
- Client acknowledged difficulty maintaining regular self-care practices during periods of high stress.
- Expressed feeling discouraged when mindfulness practices “don’t work immediately.”
- Recognised recent small wins (setting boundaries at work) but tends to discount them.
Interventions
- Cognitive restructuring to address catastrophising thoughts about work performance.
- Introduced the concept of “cognitive defusion” (from ACT) and practised a brief exercise during session.
- Provided psychoeducation about the normal course of skill-building in mindfulness practices.
Risk Assessment and Management
- Suicidal Ideation: No current or historical suicidal ideation disclosed.
- Homicidal Ideation: None reported.
- Self-harm: None disclosed.
- Violence & Aggression: None reported.
- Addictive Behaviours: None disclosed.
- Risk-taking/Impulsivity: None evident.
- Management Plan: No immediate risks identified; continue routine monitoring of mood and functioning.
Session Summary
Client continues to experience significant work-related anxiety impacting sleep and daily functioning. Insight remains good, and client is motivated to engage in therapeutic work. No immediate risks identified. Interventions focused on cognitive restructuring, cognitive defusion, and planning practical strategies to support upcoming work stressors. Small progress in boundary-setting was recognised and reinforced.
Next Steps
- Next Session: Scheduled for 7 May 2025, 2:00 PM.
- Assigned Homework:
- Complete 5 minutes of mindfulness practice daily using Headspace app.
- Draft talking points for work review and bring to next session.
