Therapy Note

Patient Details

Date: November 3, 2050
Patient ID: 241798X
Name: Isabella Garcia
Age: 42

Session Type

Clinical Therapy

Discussed Issues

Duing our session, patient Isabella Garcia expressed feelings of anxiety and restlessness. She has been dealing with lack of concentration at work, sleep disruption, and consistent worry. These thoughts and feelings are negatively impacting her daily functioning, including her performance at work and her personal relationships.

Interventions

During the course of Clinical Therapy, a combination of cognitive-behavioral therapy (CBT) and mindfulness techniques have been implemented to help deal with the patient’s anxiety. The patient was also taught breathing techniques and grounding exercises to help manage her condition during periods of intense anxiety.

Patient Response

Isabella showed good participation and compliance during the session. She actively engaged in the discussion of her anxieties and the development of solutions. She seemed receptive to the proposed techniques and displayed a positive response to the intervention measures. However, her anxiety still persists and it will require more regular sessions to observe significant improvements.

Follow-Up Plans

Isabella has been scheduled for bi-weekly 50-minute sessions for the next three months. We will focus on mastering coping mechanisms, as well as implementing CBT techniques in real-life situations she encounters. A potential evaluation for medication management may need to be explored depending on her progress in the coming weeks. The goal is to integrate her newly learned coping strategies, while managing her symptoms to improve her daily functions and enhance her overall quality of life.

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