Case Note
Case ID
Counsellor
Details
Client's first name or initials
Session Date
Session number
Session Type
Session Completed
Issues Raised
Employment Related Issues
Personal Issues
Risk Assessment
Self
Other
Clinical Scores
Clinical Outcome Total
Workplace Functionality Total
Client satisfaction
Client Case Details
Client's presenting issues:
Celina has really bad ears today it is affecting her balance. She is off work for two weeks. Her son and his girlfriend are visiting today to help in the garden. She is still looking for answers and has been on a US site but there is still little information. She is struggling with sleep again.
What does the client want from counselling?
To talk about her disease
How well is the client able to cope with their situation?
She copes depending on how bad the symptoms are each day.
What is the client’s support network? (Family, friends, GP, Mental Health team etc.)
Family and friends
Risk Management Support Plan
The risk issues presented?
No risks presented
How have you stabilised the client and what strategies did you encourage them to use?
N/A
What external support network is in place?
Counselling support
Emergency Contact Details:
Husband
Telephone Number:
07736683636
Client Case Details
Case Status
Date of next session
Tuesday, 6th April 2021
Attachments
Submitted by
Sonia Prescott
Submitted on
29th March 2021