Individual Therapy Case Study

INDIVIDUAL THERAPY NOTE

PROBLEM:
The patient was recently admitted to Behavioral Health Care (BHC) inpatient unit. The patient is diagnosed with Major Depressive Disorder.

INTERVENTION:
A 60 minute individual therapy session utilizing supportive and solution-focused interventions. Clinician discussed the patient's reason for admission and assisted the patient in identifying goals for this hospitalization and for after discharge, explored the patient's strengths and needs, conducted a biopsychosocial assessment, and established a plan of treatment with the patient.

EVALUATION:
The patient was cooperative and thought processes were well organized. The patient was alert and well oriented. Eye contact and speech were normal. Affect was appropriate. The
She reports an increase in depression during teenage years. She denies experiencing physical or sexual abuse. She reports she was emotionally abused by her parents. She denies a family history of psychiatric illness or substance abuse. She denies personal use of illicit drugs, or excessive alcohol consumption. She reports engaging in a romantic relationship with her ex-boyfriend for three years. She reports he ended the relationship in February stating he wanted to become accomplished before engaging in a romantic relationship. She has the hope that they will reconcile. The patient reports she works in the nursing field utilizing her CNA license. She reports she has the intent of attending nursing school in the fall. She reports behavioral issues while enrolled in K-12 to include suspension for slapping someone, and fighting. Upon discharge she will return to her family home where she resides with her mother and father. She reports her living