Current presentation
- Current presentation, primary concerns, or reason for this session.
- Any concerns raised by teachers, parents/carers, or other school staff.
- Current impact on functioning, including academic performance, classroom engagement, peer relationships, participation in school-based activities, and attendance patterns.
Background
- Academic history: Any academic difficulties, learning supports, or educational accommodations.
- Behavioural history: Any behavioural incidents, disciplinary actions, or classroom management strategies.
- Family/home factors: Any family circumstances, home environment factors, or parent/carer concerns affecting the student.
- Previous support: Any previous counselling, therapy, or school-based interventions.
Mental status examination
- Behaviour: Describe student’s activity level and notable behaviours.
- Speech: Comment if speech was unusually fast or slow.
- Mood: Record student’s reported emotional state.
- Affect: Describe student’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 student’s understanding of their condition.
- Judgment: Describe student’s decision-making ability.
Session content
Session content, including key themes, concerns raised by student, and topics explored. Document any school-related issues discussed such as academic stress, peer relationships, teacher interactions, bullying, or classroom difficulties. Note any family or home-related matters that impact school functioning.
Goals
Describe any therapeutic goals discussed, including academic, social, emotional, or behavioural objectives.
Interventions
- Detail specific interventions, techniques, or strategies, including any safety planning or risk management.
- Coping strategies, skills, or techniques.
- Ideas, concepts or frameworks introduced, or content of handouts or whiteboard use.
- Note student’s willingness to participate, openness to discussion, and rapport with clinician.
Progress and challenges
- Describe progress made towards therapeutic or academic goals.
- Document any setbacks, obstacles, or challenges to progress.
- Note any changes in school functioning, academic performance, or peer relationships.
Risk assessment and management
- Suicidal ideation: Describe any history of suicidal ideation, attempts, plans.
- Homicidal ideation: Describe any homicidal ideation.
- Self-harm: Detail any history of self-harm.
- Violence and aggression: Describe any recent or past incidents of violence or aggression.
- Addictive behaviours: Detail any recent or past addictive behaviours.
- Risk-taking/impulsivity: Describe any risk-taking behaviours or impulsivity.
- Management plan: Describe strategy or steps taken to manage identified risks.
Collaboration and communication
- Note any communication with parents/carers, teachers, or other school staff discussed or planned.
- Referrals made or recommended, as well as any case conferences or student support team meetings planned.
- Record any classroom accommodations, adjustments, or strategies suggested for teachers.
Next steps
- Next session: Date, time, and focus of next session
- Between-session tasks: Any activities, homework, or strategies
- Follow-up actions: Any communication, referrals, or collaboration planned with other school staff or parents.
Session summary
Brief summary of student’s current status, key issues addressed, interventions used, progress made, and next steps.
Current presentation
Mary presented as anxious and withdrawn, reporting difficulties with concentration and sleep over the past 3 weeks due to upcoming Year 12 exams. English teacher noted decreased class participation and assignment quality.
Background
- Academic history: High-achieving student with consistent A-grade performance, currently in advanced classes.
- Family/home factors: High parental expectations for academic achievement and university entrance.
- Previous support: First engagement with school counselling services.
Mental status examination
- Behaviour: Appeared restless with frequent fidgeting.
- Speech: Rapid speech when discussing academic concerns.
- Mood: Described mood as “stressed and scared” about not meeting expectations.
- Affect: Anxious and tense with occasional tearfulness.
- Thoughts: Preoccupied with academic performance and catastrophic thinking about potential failure.
Session content
- Mary expressed overwhelming anxiety about Year 12 final exams and achieving required ATAR for preferred university course.
- Described physical symptoms including sleep difficulties and morning nausea.
- Discussed perfectionist tendencies and fear of disappointing parents.
- Acknowledged avoiding study due to anxiety, then experiencing guilt about procrastination.
Goals
- Develop anxiety management strategies for exam preparation.
- Address perfectionist thinking patterns.
- Improve sleep hygiene and study routine.
Interventions
- Provided psychoeducation about anxiety and its impact on academic performance.
- Taught diaphragmatic breathing technique for immediate anxiety management.
- Introduced cognitive restructuring strategies to challenge catastrophic thinking.
- Mary demonstrated good engagement and practised breathing techniques.
Progress and challenges
- Mary showed willingness to engage with interventions and expressed relief at having support.
- Primary challenge identified is perfectionism and difficulty accepting less than perfect performance.
Risk assessment and management
- Suicidal ideation: Denied any current or past suicidal thoughts.
- Self-harm: Denied any history of self-harm behaviours.
- Management plan: Low risk profile, routine monitoring of mood and anxiety symptoms planned.
Collaboration and communication
- Mary consented to brief communication with parents regarding general support strategies.
- Planned consultation with Year 12 coordinator regarding reasonable adjustments for exam anxiety.
Next steps
- Next session: 22 March 2024 at 11:00 AM, focusing on study planning and time management strategies.
- Between-session tasks: Practice diaphragmatic breathing twice daily and implement sleep hygiene recommendations.
Session summary
Mary presented with exam-related anxiety impacting sleep and academic performance. Psychoeducation and breathing techniques were well-received, with next session focusing on practical study strategies.
