BH SOAP NOTE

docx

School

Mercy College *

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Course

MISC

Subject

Psychology

Date

Nov 24, 2024

Type

docx

Pages

Uploaded by kmdbkaity

SOAP NOTE Client Description: BH is a 30-year-old man who is single and has never been married. He is employed full-time. He is presenting with anxiety and depression. BH was dressed appropriate to season. Subjective: Client says that he is dealing with grief and guilt from the incident surrounding his girlfriend’s death. Her death was from a heroin overdose, and he woke up and she had died. Client battles addiction. Objective: BH was emotional during session when speaking of his addiction and his girlfriend’s death from a year ago. Assessment: Client made eye contact despite being emotional. CBT was used to encourage the client to work on triggers and put a plan in place to work on the triggers. Plan: Client had just dropped dirty for drugs. He was really struggling. I asked him what his triggers were to make him relapse. He wrote down 5 things that trigger him. The #1 was the death of his girlfriend. He said he laid in bed and thought more about what triggers him. He began looking back at his childhood and his mother abandoned him when he was a young boy, and she never came back in his life. His father was a good provider but lacked the nurturing component of a mother. Discussed continuing to attempt to remain clean and sober.

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