Quill generated this note with AI from the summary that was provided. The therapist can then copy-and-paste the note into their current EHR platform.
Problem:
Client presented as worn out and expressed feeling overwhelmed due to pregnancy and the associated emotional challenges. They reported anxiety about the baby's health and the impending changes post-birth. Additionally, stress was compounded by concerns over their teenage daughter's recent entry into dating.
Intervention:
The 50-minute in-office session focused on normalizing the client's feelings of being overwhelmed by significant life changes. The therapist suggested concentrating on controllable aspects, such as creating a birth plan and engaging in discussions about healthy relationships with their daughter. Time was spent on establishing potential boundaries for the client's daughter.
Response:
Client engaged in the conversation and appeared to become more grounded as the session progressed. They were receptive to the idea of setting boundaries with their daughter and the task of writing down concerns regarding the pregnancy.
Plan:
The client was assigned homework to talk with their daughter about healthy relationships and to list their major concerns about the pregnancy. The treatment plan will continue with a focus on addressing these concerns one by one. The next session is scheduled for the following week.
Today’s session was 50 minutes, in-office. Client came in looking pretty worn out, and right away they started talking about how overwhelmed they’ve been. They’re pregnant and said quote 'Everything just feels so hard right now' unquote. They’ve been dealing with all the emotional ups and downs of pregnancy—feeling really anxious about the baby’s health and how things will change once the baby’s born. On top of that, their teenage daughter has just started dating, and it’s been adding to the stress. Client said quote 'I’m just so worried, I don’t know if she’s ready for this' unquote.
We talked about how it’s normal to feel overwhelmed with so many big life changes happening at once. I suggested focusing on what they can control, like creating a birth plan and having open conversations with their daughter about healthy relationships. We spent some time discussing boundaries they could set with their daughter, to keep her safe but also give her some room to grow. Their homework is to have that conversation with their daughter this week and to write down some of their biggest concerns about the pregnancy so we can tackle them one by one. They seemed a little more grounded by the end. We’ll meet again next week.
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