Shorthand Notes -
"Clt reports ↑ anxiety, past wk, restless, incessant worrying.
Multiple panic attacks: palpitations, sweating, SOB.
Difficulty concentrating @ work, feels on-edge.
Avoiding social situations to ↓ anxiety triggers."

Data:

Client Information:

Name: [Client's Name]
Date of Birth: [Client's DOB]
Session Date: [Session Date]
Session Duration: [Session Duration]

Presenting Issues:

The client reported increased anxiety over the past week, describing feelings of restlessness and incessant worrying.
Multiple panic attacks were reported, characterized by palpitations, sweating, and shortness of breath.
The client expressed difficulty concentrating at work and a constant sense of being on edge.
There is evidence of avoidance behavior in social situations aimed at reducing anxiety triggers.

Client's Presentation:

Client appeared anxious during the session.
Exhibited signs of nervousness, such as fidgeting and shallow breathing.
Maintained good eye contact with the therapist.
Client's affect appeared distressed and anxious.

History and Background:

Briefly discussed the client's history of anxiety and panic attacks, including any relevant triggers or past experiences.
Gathered information about any recent life events or changes that may have contributed to the increased anxiety.

Client's Subjective Experience:

Client shared personal experiences of anxiety, panic attacks, and the impact these symptoms are having on daily life.
Discussed the avoidance of social situations in more detail, including specific triggers and circumstances.

Current Medication and Treatment:

Inquired about any current medications or treatments the client is receiving for anxiety.
Client reported no current medication or formal treatment.


Assessment:

Based on the client's presentation and self-report, the client is experiencing a significant increase in anxiety and is currently in a state of heightened distress.

The client's symptoms, including palpitations, sweating, shortness of breath, and difficulty concentrating, are consistent with panic attacks and generalized anxiety.

The client's avoidance of social situations is indicative of an effort to manage anxiety triggers.
No formal diagnosis has been made at this time, but further assessment is needed to determine if the client meets criteria for specific anxiety disorders.

Plan:

The client and therapist will continue to explore the client's anxiety triggers, patterns of worry, and the impact of anxiety on daily functioning in future sessions.

Psycho-education on anxiety and panic attacks will be provided to the client to enhance their understanding of their symptoms.

The therapist will introduce relaxation and grounding techniques to help the client manage anxiety in real-time.

Further assessment will be conducted to determine if the client may benefit from medication or additional therapeutic interventions.

The client will be encouraged to maintain a journal to track anxiety symptoms, triggers, and progress.

The therapist and client will collaborate on setting specific goals for therapy and treatment.

The next session is scheduled for [Next Session Date and Time].