Free Mental Health Case Note Template
Mental Health Case Note
Prepared By: [Your Name]
Company: [Your Company Name]
Client Information
Client Name: Lawrence Orn
Client ID: 123456789
Date of Session: March 5, 2060
Time of Session: 10:00 AM
Clinician Name: Dr. Sigmund Corwin, LMFT
Presenting Problem
Lawrence expressed feelings of persistent anxiety and difficulty sleeping over the past month. He reports that his workload has increased significantly, which has led to feelings of overwhelm and irritability.
Session Notes
A. Subjective Observations:
He mentioned experiencing muscle tension and headaches, which he attributes to stress.
"I feel like I’m constantly on edge. Even when I try to relax, my mind keeps racing about all the things I have to do."
-Lawrence
B. Objective Observations:
Lawrence looked visibly exhausted and uneasy, often displaying signs of restlessness throughout the session. He couldn't seem to sit still for long, frequently fidgeting in his seat. When he spoke, his words came out hurriedly and insistently, and he tended to abruptly change subjects without warning, making it challenging to follow the train of conversation.
C. Assessment:
Lawrence is exhibiting symptoms consistent with Generalized Anxiety Disorder (GAD), including excessive worry, physical tension, and sleep disturbances. His reported symptoms align with the DSM-V diagnostic criteria for GAD.
D. Plan:
-
Introduced breathing exercises to help Lawrence manage stress.
-
Recommended starting a daily mindfulness practice using guided meditation apps.
-
Scheduled a follow-up session for March 12, 2060, to assess progress.
Interventions Used
-
Cognitive Behavioral Therapy (CBT): Explored and addressed the various distorted thinking patterns that are often associated with stress related to workloads, taking steps to identify and manage these patterns effectively.
-
Psychoeducation: Explained the physiological effects of anxiety and how mindfulness can help regulate these responses.
Client Response
Lawrence was receptive to the interventions and expressed interest in trying the mindfulness exercises. He reported feeling slightly more relaxed after practicing a brief breathing exercise during the session.
Follow-Up Actions
-
Complete a stress journal to identify triggers and patterns of anxiety.
-
Explore relaxation techniques, such as progressive muscle relaxation, before bed.
-
Review progress on managing workload during the next session.
Clinician Signature:
Dr. Sigmund Corwin, LMFT
March 5, 2060
