DATA
Summary of Session
The client presented herself on time for the Session and was Euthymic with congruent affect. However, he stated that he was not doing well and that he was much disturbed by the break. We discussed and agreed on her goals for the year to be less hard on himself and extensively explored ways she could use to achieve that. We reviewed a helpful cognitive behavioral therapy thought and an unhelpful thinking styles worksheet during this Session and discussed whether he would like to document some of the unhelpful negative thoughts during this Session, something that he agreed. However, he only thought it would be well to complete it during the next schedule.
Medicated-assisted treatment
Reviewed by…………… on 13/03/2020 8:00 am
Allergies
Reviewed by…………… on 13/03/2020 8:00 am
Observations
Physical status: Dressed casually, neat, and well-groomed.
Relatedness: good
Attitude: cooperative
Eye contact: poor
Motor behavior: average
Mood: Euthymic with congruent affect
Speech: not clear with distorted volume and rhythm
Concentration/attention
Easily distracted
ASSESSMENT
The patient was quiet, engaged, and tearful throughout the Session as he spoke about the unnecessary pressure he puts himself. He was largely careful and interested in processing the issue in the future. However, he was unsure about the reason for his high expectations.
Axis one
Diagnosis differed on-axis one
Axis three
Diagnosis differed on axis two
Axis three
Diagnosis differed in axis three
Axis Four
Adjustment to life cycle transition (4b6)
Axis five
GAF 70-61: mild to moderate difficulties of functioning
PLAN
The client is scheduled to return after three weeks to review his cognitive behavioral therapy thought record and extensively discuss what unhelpful thinking styles he identified by himself.
Anticipated focus on next Session
- Issues underlying present concerns
Deposition
Return visit (3 weeks)
Signed by…………………….., title on 13/04/2020 9:30:27 am
- CASE II: UNCOUNCIOUSNESS.
Client Pt. #: 57879 Date of Birth1984 Age 34 Sex: Male
Client Pt. #: 57889 Date of Birth 1988 Age 30 Sex: female
Session two
DATA
Summary of Session
Met John and Jane for a one-hour session where Jane reported she was sleeping less and unable to concentrate at work, although he does not think it is due to starting Prozac two weeks ago. Both reported increased frequency and effectiveness in their communication due to their speak-listen homework. However, Jane stated that John still does not open up on conversation as much as possible soothing that John feels the assessment is wrong and really spilling his guts. The Session also focused on their differing views of possible relationships and openness to the origin of family issues. In this Session, Jane interrupted John four-five times to add to her statement something that aggrieved John, and after the fifth time, he sat quietly and stated that Jane should hire his views. Moreover, Jane shouted at John that he was quiet, and after a few moments, he apologized.
ASSESSMENT
John’s symptoms of depression seem to lessen, and the couple has improved their communication skills and style. However, they have not rebuilt their trust and unity. Jane views John that he is not trying and, therefore, not caring.
PLAN
The couple is scheduled to return after two weeks to continue building their communication skills, style, and safety
Anticipated focus on next Session
- What new did you learn from the point of your wife/husband?
Return visit (2 weeks)
Signed by…………………….., title on 13/04/2020 9:30:27 am
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