Patient Number: 01
Client Information: • Initials: LG
· Age: 69
· Gender Identity: Female
Visit Information: Psychotherapy session, outpatient clinic (50 minutes) Practice Management: Follow-up visit planned in 2 weeks.
Diagnosis: • Primary: Adjustment Disorder with depression
Rule Out: Persistent Depressive Disorder
Treatment Plan and Notes: Patient described chronic low mood and feelings of loneliness since retirement. Intervention focused on interpersonal therapy (IPT) techniques to improve communication and strengthen social supports. (CBT) techniques will be used in cognitive restructuring to address negative internal dialogue around grief. Client will be provided resources for senior social activities.