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Example of Clinical Note

The document summarizes a clinical note for a client's second therapy session. The client reported having a difficult week and discussed challenges with her children and ex-husband. The therapist listened and provided CBT and breathing techniques. The plan is for the client to continue twice weekly sessions and see her PCP about adjusting depression medication.

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71 views2 pages

Example of Clinical Note

The document summarizes a clinical note for a client's second therapy session. The client reported having a difficult week and discussed challenges with her children and ex-husband. The therapist listened and provided CBT and breathing techniques. The plan is for the client to continue twice weekly sessions and see her PCP about adjusting depression medication.

Uploaded by

Brianna
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Example of a Clinical Note

Client Name: Jane Doe DOB: 1/15/1972


Location: Office Minutes to Bill: 60
Service: Individual Psychotherapy Time Start: 9:00 am Time End: 10:00am
In Attendance: Ms. Doe and therapist

Presentation Memo: This is Ms. Doe second session. Client was on time for this
session. Ms. Doe continues to show signs of depression.
Main Diagnosis: Adjustment Disorder with anxiety and depression mood
Goal Memo: The goal of this session was to continue to gather information. To
review what happened since the last session. Note: During the first session the
therapist did explain rules and expectations of counseling. The client completed all
paperwork. Therapist uploaded all of the client’s paperwork.
Intervention Memo: Therapist listened, CBT, Deep Breathing Method.
Risk Assessment Memo: Ms. Doe does not show/display risk; to self or others at
this time.
Data: Ms. Doe informed the therapist that she had a difficult week; since the last
session. Ms. Doe spoke about all of the events and tasks that she has on her plate.
Ms. Doe has two children (John and Joe). John and Joe are twins (14 years old).
Client is having a difficult time with her kids; during chores around the house.
Client works 35 hours per week. Her kids play soccer and basketball. Her kids
have other committed duties after school. Client is divorce; from kids’ father. Ms.
Doe spoke about her relationship with her husband. Client informed the client that
her ex-husband only helps when needed; when it comes to their children. Client is
currently dating however; it can be a challenge due to her daily lifestyle. Client
spoke about her best friend (Jazmin). Client stated that she is very supportive and
help the client a lot with the kids. Her best friend cares for the kids; when the
client has to go out of country for work. The client expressed her concerns of her
depression medication not working. Client explained that she often feels sad. This
is more than normal.
Assessment: Ms. Doe arrived early for session. Client continued to be neatly
groomed and well dressed. Client seemed to be a little frustrated at the being of the
session. Ms. Doe was texting during the session. Client was told not to text during
the sessions. Client got up and walked around the room; during this session.

Plan: Client and therapist will continue to meet for individual therapy twice per
week. Ms. Doe is scheduled to be seen on Monday 1/27/2020. Therapist will
continue to listen to the client and gather information for treatment plan. Ms. Doe
will continue to write in her journal. Client is encouraged to use the deep breathing
method; when the client is feeling stress. Client is encouraged to see PCP for
possible increase in medication (Zoloft). Client will work a schedule for her kids to
help around the house.

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