Presenting problem
The client is seeking help for low mood and loss of interest in daily activities, beginning about 4 months ago after a redundancy.
Medical and substance history
The client reported no medical conditions and no current medication. Sleep: early waking most days. Alcohol: 2 to 3 drinks on weekends. Other substance use: not assessed. (appears in this excerpt)
Psychological history
One prior episode of low mood at age 24, untreated. Hospitalizations: not assessed.
Social context
Lives with a partner, described as supportive. Currently unemployed; in contact with two friends.
Mental status
Casually dressed, cooperative. Speech quiet and slow. Affect flat. Thought process linear.
Risk assessment
Risk not assessed in this session.
Strengths and resources
Supportive partner; prior work history the client described as a source of pride; attended on their own initiative.
Formulation and recommendations
The clinician described the presentation as consistent with a depressive episode following job loss, and recommended weekly sessions and a risk review at the next appointment.