Sarah -u10d1-Soap Note XYZ Case Study)

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University of Houston, Downtown *

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4303

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Psychology

Date

Apr 30, 2024

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pdf

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2

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SOAP NOTE FORM SOAP NOTE FORM Client: Sarah Date: 03/11/2024 Subjective: Client's reported feelings and/or subjective information which are clinically significant captured as a summary or sometimes as a direct quote from the client. Example: "Sometimes I get mad and act crazy." Sarah is a 15-year-old Black female who lives at home with her parents and is a freshman in high school. She reports her school counselor suggested she seek counseling so that she has additional support for the struggles she is experiencing at home and learn how to "deal with my mother.". Sarah reports constantly feeling "sad" and can't remember a time when she was not sad. Sarah stated she has no brothers or sisters and does not know who her father is or where he lives. Sarah reports having a grandma who lives in Florida, but she does not get to talk to her very often. Objective: Include observable information or data that is connected to the client's subjective information. This data should be facts and will include issues addressed during session. Statements related to appearance, attitude, orientation, affect, mood may be placed in this section as well. Sarah reports that when she was 10, her mother's boyfriend sexually assaulted her on a weekly basis while her mother was at work. She reports this lasting for "almost a year. Sarah stated her mom has physically and emotionally abused her for "as long as I can remember She stated she has been using opiates for about 6 months and that she "loves the feeling because it gets rid of my anxiety." Sarah reports her use has increased from taking one pill a day to at least 4 to 5 pills per day. Assessment: Clinical impressions and judgments connected back to (S) and (O), diagnosis (if applicable), prognosis, progress:
Sara is showing a great sign of substance use disorder and anxiety; she stated that her childhood experience was a struggle; her mom’s alcoholic boyfriend sexually molested her at a very young age, and she never related this to anyone, the result of this post-traumatic stress. Was her use of opiate to cope with the anxiety? The daily use increased due to the feeling that she was deriving from it, and she had no desire to stop using. Plan: Plans for future therapy session, any homework, referrals to outside resources. Example: Continue with individual and family work; make appointment to see physician; restrict socialization to family circle; structure time. During the first two weeks of Sarah's treatment, she will meet with a treatment team three times a week. After that, she will meet with an assigned behavioral therapist in an outpatient unit two times a week. Sarah will also register with medicated assisted treatment (MAT) to receive methadone or suboxone, and she will receive pamphlets to join a Narcotics Anonymous group (NA). Sarah will recover from PTSD, anxiety, and her opiate addiction with the help of these treatments, as well as a peer support group to avoid relapse. Therapist: Therapist Name/Credentials: Edmondson Chukweuzi, LMHC Date: 3/11/2024
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