Notes.docx – Assignment:

Client Therapy session:
N. E. is a 28 yr old Caucasian Female. She works full time, is a mechanic by occupation.
Has been in Therapy since August 2022. Main Diagnosis are Depression and Anxiety
She came in for concerns about fluctuation of mood, decreased appetite, and weight loss.
Height= 5”5” tall Weight= 118 lbs
Patient states “I am very insecure about my weight, people comment on how skinny I am, tell me I need to eat more, and I look like a skeleton”.
Patient also states her strained relationship with her father adds to her stress, her father is a drug addict, and hasn’t spoke to him since she was 18 yrs old, but her brother has been pressuring her to amend their relationship. Stated that her relationship with her brother has been “weird” because she tends to avoid him as of late, because he constantly wants to talk about their father, and she does not. States she sleeps okay no trouble falling asleep, just went through a breakup with her boyfriend 9 months ago and is currently “trying to find myself”. States she has a hard time making friends and only has one friend. States she feels lonely at times, but its better than having friends and family that trigger her. Not on any medication currently. Was on Lexapro 5 yrs ago due to severe depression at the time that resulted after a long-term relationship breakup. Not on any appetite stimulants, states she plans on eating at least 2 meals a day. Due for her annual physical with her primary care doctor in 3 months.
Denies any drugs and alcohol.
Denies any Homicidal /suicidal ideation.
Plan to continue weekly visit.
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