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:
resenting Issues:
The client stated she is getting a lot of anxiety about returning to work during the next few weeks. She is struggling with depression and anxiety. The client states she is feeling anxious, tired and tearful and struggling to cope. The client presents with anxiety and low mood . She is tearful and emotional.
What does the client want from counselling?
What does the client want from counselling?
The client as in all of the previous sessions wants counselling to continue to be a safe space to explore their thoughts and feelings around her childhood, family life and her present day life. She would like to be able to validate her emotions and identify underlying reasons for being low in mood all of the time. she also states she is not sleeping well. The client would like to explore positive coping mechanisms for her future, thus working towards improving her overall EHWB
How well is the client able to cope with their situation?
The client states as in all the previous sessions that she is still struggling to cope with her thoughts, feelings and emotions around areas of her life hat she is still struggling to understand and cope with.
She states she is in her own words "I am still trying to do the talking out loud, being positive about me, but that isn't working all of the time and I want it to work all of the time". This statement was explored for the whole session.
She also again explored her role in the 'Drama Triangle' and the negative impact, and recognising her being again 'stuck' in this situation is having on her overall EHWB.
As homework the client is again going to reflect on herself and what it will take for her to feel good about her, the role she can play in this and how she would/could change that role for her. To try to acknowledge and accept that what happened in her past was not her fault or her responsibility.
What is the client’s support network? (Family, friends, GP, Mental Health team etc.)
The client states as the previous sessions she has support in her mum, step-dad, sister and partner.
Risk Management Support Plan
The risk issues presented?
How have you stabilised the client and what strategies did you encourage them to use?
What external support network is in place?
Emergency Contact Details:
Telephone Number:
Client Case Details
Case Status
Date of next session
Monday, 5th April 2021
Attachments
Submitted by
Maria Hindle
Submitted on
29th March 2021