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:
Daniel was very emotional today. He feels in his words drained, crippled, overwhelmed, paranoid and his whole body feels like concrete. He physically struggled to get out of bed this morning. He feels he can't face the day ahead. He really enjoys his job and he says that's not the problem. There are days when he is off when he feels exactly the same. He is worried that he is going to be as bad as his mother was with her mental illness as the antidepressants are not helping. He has an appointment with his GP again this coming Thursday to address these issues as he doesn't feel he is being heard. He is now back on his full-time rota. He reversed into his neighbours tree yesterday.
What does the client want from counselling?
To talk about his mental well-being and how this affects him every day.
How well is the client able to cope with their situation?
He goes to work and does his day-to-day duties but is not coping mentally at all.
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 but I feel a psychological assessment of some sort would be beneficial. I have discussed this with my client as counselling and antidepressants are not working
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
Emergency Contact Details:
Partner
Telephone Number:
07964714780
Client Case Details
Case Status
Date of next session
Tuesday, 13th April 2021
Attachments
Submitted by
Sonia Prescott
Submitted on
29th March 2021