Date:
Client:
Other Attendees:
Client Situational Summary:
- Summary of the client’s current living situation or immediate context.
Presenting Issues / Session Focus:
- The client’s presenting issues and what led them to attend today’s session.
- Summary of the topics discussed during the session.
- Any immediate concerns or crises raised by the client.
Psychosocial Observations:
- Client’s affect, engagement level, and overall presentation.
- Any notable changes from previous sessions as identified by the social worker or the client.
- Demonstrated strengths, including any helpful resources the client has previously accessed.
Services Provided / Interventions:
- What the social worker did during the session (e.g., counselling, case management, referrals, advocacy, psychoeducation).
- Any specific evidence-based therapy modalities used (e.g., CBT, ACT, DBT).
- Resources, referrals, or other case management activities provided.
Progress Toward Goals:
- Brief update on treatment or service goals.
- What is working and what barriers exist.
- Any development of or changes to the service plan.
Risk Assessment & Management Plan:
- Safety concerns (e.g., self-harm, housing instability, basic needs).
- Strategies or steps taken to manage identified risks (e.g., suicidal ideation, substance use, risk-taking behaviour).
- Protective factors that mitigate risk.
Follow-Up & Next Steps:
- Action items for the client (e.g., homework tasks, appointments to make).
- Action items for the social worker (e.g., coordination with stakeholders, services, or organisations).
Next Session:
- Date and time of the next session.
- Any plans or focus areas for the next session.
Date: 14 February, 2026
Client: Mary Bloggs
Other Attendees: Emma Brown (client’s mother), present for the first 15 minutes of the session.
Client Situational Summary:
- Ms Bloggs is a 28-year-old woman currently residing with her mother in a two-bedroom unit in western Sydney. She has been unemployed for approximately four months following a period of redundancy from her role in retail. She is currently receiving JobSeeker payments and reports ongoing financial stress.
Presenting Issues / Session Focus:
- Ms Bloggs presented today reporting increased anxiety and low mood over the past fortnight, which she attributed to financial pressures and difficulties maintaining a routine since losing employment.
- She described disrupted sleep (waking frequently through the night), reduced appetite, and withdrawing from social activities she previously enjoyed.
- Ms Bloggs also discussed interpersonal tension with her mother, who she feels is critical of her job search efforts. Ms Brown was invited into the session briefly to discuss communication strategies, and both parties engaged constructively.
- Ms Bloggs expressed frustration with the Centrelink reporting process and requested assistance navigating mutual obligation requirements.
Psychosocial Observations:
- Ms Bloggs presented as tearful at times but was cooperative and engaged throughout the session. Her affect was congruent with the content discussed.
- Compared to the previous session, Ms Bloggs demonstrated improved ability to articulate her emotional experiences, using language consistent with psychoeducation provided in earlier sessions.
- Strengths noted include her willingness to involve her mother in the session, her continued attendance at fortnightly appointments, and her use of a mood tracking app recommended at a prior session.
Services Provided / Interventions:
- Supportive counselling was provided, with a focus on validating Ms Bloggs’ emotional experience and normalising her response to ongoing stressors.
- Brief CBT-based intervention was used to identify and challenge unhelpful thought patterns related to self-worth and employment status. A thought record worksheet was introduced and completed collaboratively in session.
- Case management activities included reviewing Ms Bloggs’ Centrelink obligations and drafting a plan to contact her employment services provider to clarify mutual obligation requirements.
- A referral was made to the local community centre’s free financial counselling service.
Progress Toward Goals:
- Goal 1 — Improve mood and daily routine: Partial progress. Ms Bloggs has re-established a morning routine on most days but continues to struggle with motivation in the afternoons. Sleep difficulties remain a barrier.
- Goal 2 — Obtain stable employment: Limited progress due to reported low confidence and anxiety about interviews. Agreed to focus on building interview skills as a sub-goal over coming sessions.
- Goal 3 — Strengthen social connections: Ms Bloggs reported attending one social outing in the past fortnight, which she described as positive. She identified this as an area she would like to continue working on.
Risk Assessment & Management Plan:
- No current suicidal or self-harm ideation reported. Ms Bloggs denied any thoughts of self-harm when asked directly.
- Mild risk related to social isolation and financial stress was noted. Protective factors include a supportive relationship with her mother (despite current tensions), ongoing engagement with this service, and motivation to improve her situation.
- No changes to the current risk management plan.
Follow-Up & Next Steps:
- Client tasks:
- Complete one thought record between sessions using the worksheet provided.
- Attend the financial counselling appointment once scheduled.
- Continue using the mood tracking app daily.
- Social worker tasks:
- Contact Ms Bloggs’ employment services provider (JobActive) to clarify current mutual obligation requirements and advocate for appropriate accommodations.
- Send referral details for financial counselling to Ms Bloggs via email.
- Follow up with Ms Brown (with Ms Bloggs’ consent) regarding the communication strategies discussed.
Next Session:
28 February, 2026 at 10:00 AM. Plan to review thought records, follow up on the financial counselling referral, and begin structured work on interview skills.
