Description
Name: Mrs. AB Date of Termination Summary: October 30, 2019
Date of First Consultation: June 3, 2019 Date of Last Consultation: October 25, 2019
Date of First session: June 14, 2019
Duration of the Treatment: Five months (Total of 20 sessions, missed 4 sessions and attended 16 sessions).
• Presenting problem
• Major psychosocial issues
• Types of services rendered (i.e., individual, couple/family therapy, group therapy, etc.)
• Overview of treatment process
• Goal status (goals met, partially met, unmet)
• Treatment limitations (if any)
• Remaining difficulties and/or concerns
• Recommendations
• Follow-up plan (if indicated)
• Instructions for future contact
Summary of the Presenting Problem:
Possible DSM-5 Diagnosis: Adjustment Disorder (with anxiety)
The client is a 65 year old African American widow. Her husband passed away ten years ago. Client came to counseling complaining of feeling anxious, not sleeping well and difficulty concentrating. She reported she is constantly worrying and feel very tired and overwhelmed. These feelings began after her only son was drafted to Japan eight months ago. She explained she believes in family dynasty and has always been surrounded by family even as a child. Client has 2 daughters who live out of state with their families and her only son lives 20 minutes away from her. Client feels overwhelmed with this change and expresses fear of being alone without her family around. This was her first visit to a mental health professional for psychotherapy.
Overview of the Treatment Process:
The client was seen on a once per week basis in 20 sessions of individual psychotherapy with the incorporation of cognitive-behavioral techniques to address her anxiety, lack of concentration and insomnia. Though the client’s presenting difficulty included not been consistent with attending therapy or counseling sessions, she missed four sessions of therapy and the was able to continue with her sessions with the support of her family.
Sample Solution
