Professional Documents
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Services:
( ) med. check - 1/4 hr.
( x) individual therapy - 1/2 hr. ( ) individual therapy - 1 hr. ()familytherapy -1/2hr.
()familytherapy - 1hr.
( ) group therapy - 1 hr.
( x) weekly
()2weeks
()3weeks
( ) other _____________________________
DESCRIPTION: client seeks therapy due to feelings of low mood, inability to sleep, relationship
concerns, guilt and outburst.
The CLT came in due to difficulty sleeping, relationship concerns, outburst, guilt and the
pressure of it all. Client is actively engaged in session and cognitively aware. Client affect
appeared depressed and distressed. The therapist reflected to the client what was heard from the
client and walked the client through her life history.
ASSESSMENT/DIAGNOSIS: the therapist assessed the clients motivation the client motivation
is her desire to find a resolution to her concerns, The client symptoms are consistent with
depression
PLAN: therapist suggested to have the client journal about her thoughts and feelings daily to
help reduce the clients feelings of guilt. As well therapist will have client use thought stopping to
decrease maladaptive behaviors and outburst
Signature ______________________________