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
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Clinical Scores
Clinical Outcome Total
Workplace Functionality Total
Client satisfaction
Client Case Details
Client's presenting issues:
My client said he does feel better he is not in a low at the moment he talk about his lows and highs and how he can get real highs where he is laughing and quite hyper and then he gets really low which can last for weeks on end and then he gets really negative thoughts in his mind. I talked to my client about getting a psychiatric assessment he said he is willing to do this as he has never had one before i informed him a consent form will be out to him soon. my client went on to say how he is on in a low at the moment at all and feels quite possitive.
What does the client want from counselling?
How well is the client able to cope with their situation?
What is the client’s support network? (Family, friends, GP, Mental Health team etc.)
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
Attachments
Submitted by
Seth Theodore
Submitted on
29th March 2021