Case Notes
Name of Client : Drake
Session Number: 1
Date: 06/04/2022, 12:30 pm
Topics discussed during the
session
Means of achieving the goals
and objectives
Interventions and techniques
used during the session and
their effectiveness
Observations
Progress or setbacks
Signs, symptoms, and any
increases or decrease in the
severity of the behaviors as
they relate to the main
concern
Homework assignment
Client’s current strengths and
challenges
PSYCHOLOGICAL NOTES AND MENTAL STATUS
Drake has to juggle work and studies at the same
time to assist his parents.
He said that he struggles with time management
because of procrastination which results him in
getting stressed in coping up with his school
requirements. He also doesn't want to share his
emotional burdens to anyone. He is slowly losing
his concentration with his studies.
But he wanted to be successful. He is hesitant to
reveal his real gender orientation to his parents.
Psychotherapy was needed to teach him
psychosocial strategies to manage anxiety
associated with interpersonal conflicts such as:
apprehensions on coming out regarding his real
gender identity to his parents, work demands,
school stressors, time management issues and
procrastination.
Cognitive behavioral therapy
Time management techniques
Calming skills
Stress management techniques
The client acts in polite manner
He emphasizes his goals and what he wants to
accomplish.
He appears to be enthusiastic and full of energy,
and is talkative as he interacts with us confidently.
He is independent and can decide on his own. He
doesn’t want to share his problems as much as
possible with anyone.
The client exhibits a high degree of intelligence.
He wasn’t able to finish his activities in school on
time. He is fond of procrastination.
Lack of sleep; restlessness
Easily fatigued
Loss of interest with his studies.
None
Poor in managing his time as a working student.
He feels stressed due to his academic workloads.
Client Information
Name: Drake
Age: 21
Profession: Search Engine Evaluator/ social media rater

Psychological Notes

Presenting Problem:
Lack of sleep; restlessness
Easily fatigued
Loss of interest with his studies
Worrisome

History of Presenting Problem:

He is studying and working at the same time which causes him to struggle on time
management because of procrastination habits which result him in getting stressed in
coping up with his school requirements. He keeps his problems to himself, and is slowly
losing his concentration with his studies though he wanted to be successful. He is
hesitant to reveal his real gender orientation to his parents.

Findings and Conclusion:

Drake has generalized anxiety disorder (GAD). His treatment plan centered on cognitive
behavioral techniques which we focused on teaching him specific skills to directly
manage his worries as well as educating him about the cycle of worry by teaching him
how to distinguish between productive and unproductive worry.

Professional Advice/Recommendations

Recommendation
• In Treatment Plan

Mental Status Examination

Dress and Grooming.

He was wearing a plain white shirt.
His grooming was adequate.
Appeared older than his stated age.

Attitude Polite and agreeable.

Facial Expression Relaxed and calm.

Behavior Cooperative, high self esteem

Psychomotor Activity n/a

Speech and Language. Calm

Mood. Positive mood.

Affect. Normal range.

Orientation and level of Consciousness Normal.

Attention Normal.

Memory Impairment n/a

Disordered Perception n/a

Thought Content Feelings of adequate self-

esteem
Thought Process Coherent

Preoccupations n/a

Suicidality and/or Homicidally n/a

Impulse Control Normal.

Insight Good.
Judgement Good.
Insights
The client shows some insight and judgment regarding her anxiety and need for
help.

Date Complied: June 16, 2022

Prepared by:
Roxanne V. Bumanglag
Bachelor of Science in Psychology
Intern