Mental Health Soap Note

SOAP Note

Prepared by: Maranda M. Ochs, Future Glow Dynamics

Date: January 5, 2050

This SOAP Note is a professionally structured report, designed for mental health professionals to evaluate and plan the treatment strategy for Ethan Wilson. The document delves into the Subjective and Objective observations, leading to an Assessment and eventually forming a conclusive Plan.

S

O

A

P

Subjective

  • Patient: Ethan Wilson

  • Age: 26 years

  • Gender: Male

  • Height: 5'9"

  • Weight: 160 lbs

Objective

  • Patient appears anxious and restless

  • Reports difficulty in concentrating

  • Experiencing sleep disturbances

  • Expresses feeling of emptiness and hopelessness

Assessment

Mental Health: The patient shows symptoms commonly associated with severe anxiety and depression. His inability to focus, distress, and statements about hopelessness are concerning.

Plan

  • Commence Psychotherapy: Cognitive behavioural therapy (CBT)

  • Pharmacological intervention: Antidepressants

  • Follow-up consultation in two weeks

  • Mental health maintenance strategies to be discussed in subsequent sessions

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