Therapy Soap Note
Therapy Note
Subjective Feedback
Client: Carlos Martinez
Date of session: July 13, 2051
Mr. Martinez began our session by sharing his recent feelings of anxiety and stress related to his job and familial concerns. He reported feeling overwhelmed and unequipped to handle confronting his emotions and feelings. Carlos expressed a lack of motivation in daily routines and activities he once enjoyed, such as reading and going for walks. He has also mentioned having disrupted sleep patterns.
Objective Observations
Carlos presented as anxious throughout the session. His voice was shaky and his body language amplified his discomfort. He had difficulty maintaining eye contact, which might indicate low self-esteem. Despite these indications of anxiety, Carlos was willing to engage in the therapeutic process. He was particularly responsive to discussing coping strategies.
Clinical Therapy Assessment
Considering Carlos's reported symptoms and observed behaviours, a preliminary diagnosis of Generalized Anxiety Disorder could be considered. It should be noted that further evaluation and possibly psychological testing is needed to confirm this diagnosis. His difficulty to regulate emotion and handle stress, along with reduced motivation and disrupted sleep, all align with this preliminary assessment.
Plan in Therapy
Moving forward, the primary objectives for Carlos’s therapy will be to reduce his anxiety levels, improve his stress management skills, increase his self-esteem, and enhance his overall quality of life. To achieve these goals, cognitive-behavioral therapy (CBT) will be introduced. This will involve assisting Carlos in identifying and altering negative thought patters that may contribute to his anxiety, teaching him effective coping strategies, and helping him to regain the motivation he has lost in his daily activities.
Carlos, with his agreement, should be scheduled for weekly psychotherapy sessions. These sessions will focus on utilizing CBT strategies as well as incorporating mindfulness-based stress reduction techniques, where appropriate. Moreover, a referral for a psychiatric evaluation could be considered, to explore if medication could be a beneficial supplement to our therapy.
