Mia Chen
Client reports feeling "on edge" most days over the past 2 weeks, with trouble falling asleep and alot of worry about work performance. Client says her manager has increased her caseload and she is not sleeping more then 5 hours. Denies SI/HI.
Client presented well-groomed, mildly restless, speech normal in rate and volume. GAD-7 score today 14 (moderate), up from 9 at intake. Affect anxious but reactive.
Presentation consistent with GAD, symptoms worsening in the context of an increased workload. Good insight and engagement with the process, client is motivated to make changes.
Continue CBT weekly. Introduce sleep hygiene protocol and worry-postponement exercise as homework. Re-administer GAD-7 in 4 weeks. Review with GP regarding medication if there is no improvement at that point in time.
Mia Chen
Psychotherapy · August
| Item | Code | Qty | Amount |
|---|---|---|---|
| Psychotherapy, 60 min Tue 4 Aug · Telehealth | 90837 95 | 1 | $220.00 |
| Psychotherapy, 60 min Tue 11 Aug · In person | 90837 | 1 | $220.00 |