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:
Client has experienced manic moods - nearly bought a second car although she has no money.
Her sister has suggested she may be bi-polar.
She feels 'scatty' and ungrouded.
Her partner is on a programme to steer clear of drugs.
What does the client want from counselling?
To feel more certain as to what she wants to do, particularly in relation to her boyfriend.
Has given a time frame of her birthday 0n 3/05/21 to decide if she wants to be with him.
How well is the client able to cope with their situation?
Currently not too well although she has been talking to her mother and her sister and as a result feeling calmer.
What is the client’s support network? (Family, friends, GP, Mental Health team etc.)
Her sister, her mother and a few friends.
Risk Management Support Plan
The risk issues presented?
None
How have you stabilised the client and what strategies did you encourage them to use?
Used session to look at how to feel in control without it being through food and exercise as she tends to do.
Explored ways to be more rational and acknowledge how she can make herself happier.
What external support network is in place?
N/A
Emergency Contact Details:
Telephone Number:
Client Case Details
Case Status
Date of next session
Wednesday, 7th April 2021
Attachments
Submitted by
Maggie Harris
Submitted on
29th March 2021