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Telehealth notes
Telehealth
00:00:00
Clinician
Good to see you again. How have things been since our last session?
Patient
It’s been okay, but I’m still struggling with social anxiety, especially at work. We’ve had a few networking events recently, and I just feel tense the whole time. Afterward, I keep replaying conversations in my head and wondering if I said something weird.
Subjective
Client Report/Presenting Problem
The client, a 29-year-old male, reported ongoing social anxiety, particularly in group and networking situations, often followed by self-critical rumination. He noted increased irritability and sleep disruption over the past two weeks due to work stress but highlighted that regular exercise helps manage his mood. He expressed a goal to improve confidence in social interactions and reduce anxiety.
Objective
Observations
- Well-groomed, casually dressed
- Neutral mood, mild anxiety when discussing social situations, appropriate affect
- Coherent speech, normal rate and tone, with intermittent but appropriate eye contact
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