Client: Jane Doe, a 38-year-old female client who has been attending weekly therapy sessions for generalized anxiety and relationship stress.
Therapist: Dr. Smith, a licensed clinical psychologist
Date/Time: October 10, 2023, 2:00 PM - 2:45 PM
Modality: Video telehealth session (client in private home office, therapist in private office)

Presenting Problem:
Jane has been experiencing increased anxiety, irritability, and difficulty concentrating on personal and professional tasks. She is concerned about her ability to manage stress related to upcoming changes at work and tension in her relationship with her partner.

Sample Transcript & Observations:

2:00 PM - 2:05 PM (Check-in & Rapport Building)
	•	Therapist: “Hi Jane, it’s good to see you again. How have you been since our last session?”
	•	Client (Jane): “I’ve felt pretty overwhelmed this past week. My workload at the office nearly doubled, and my partner and I had a few arguments about household responsibilities.”

Therapist’s Notes (Not said aloud): Jane appears somewhat tired; she’s rubbing her temples and has a tense expression. She’s making consistent eye contact but is fidgeting with a pen.

2:05 PM - 2:15 PM (Exploration of Symptoms)
	•	Therapist: “You mentioned feeling overwhelmed. Can you tell me more about what’s been making you feel that way?”
	•	Client: “At work, I’m worried I can’t keep up. My manager just assigned three new projects. I’m not sleeping well because I’m anxious about meeting deadlines. I wake up around 4:00 AM every day, heart racing.”
	•	Therapist: “You mentioned last session that you were using some deep breathing techniques. How has that been going?”
	•	Client: “I tried once this week, but I felt too restless. I ended up just scrolling through my phone instead, which probably made it worse.”

Therapist’s Notes: Jane reports continued anxiety, difficulty sleeping (waking early and feeling restless), and shows signs of muscle tension (clenched jaw, rubbing neck).

2:15 PM - 2:25 PM (Discussing Relationship Stress)
	•	Therapist: “You said you had a few arguments with your partner. Can you share what led to those conflicts?”
	•	Client: “We’ve been arguing about chores and who’s responsible for what. I feel like I’m doing most of the housework. My partner says I’m too critical and not asking for help directly. I guess I’m not communicating well.”
	•	Therapist: “Have you tried implementing any of the communication strategies we discussed last time, like using ‘I’ statements or scheduling a set time to talk about chores?”
	•	Client: “I tried once, but it felt forced. I ended up just complaining about how stressed I am. I know that didn’t help.”

Therapist’s Notes: Jane acknowledges difficulty implementing previously discussed communication strategies and expresses guilt and frustration about these interactions.

2:25 PM - 2:35 PM (Coping Strategies & Goals)
	•	Therapist: “It sounds like the stress at work and home is contributing to your anxiety. Let’s revisit some coping techniques. We talked about structured problem-solving and brief relaxation exercises. Are there any moments during the day you could schedule a short break to practice deep breathing or a quick mindfulness exercise?”
	•	Client: “I think I could try taking a five-minute break mid-morning. Maybe stepping away from my desk and doing some guided breathing could help.”
	•	Therapist: “Great. Let’s also consider a small goal for communication at home. Perhaps one evening this week, you could let your partner know when you’re feeling overwhelmed before it escalates. You could say, ‘I’m feeling anxious about work and need a few minutes to gather my thoughts.’”
	•	Client: “I can try that. I don’t want to keep arguing. I want to feel more in control of these situations.”

Therapist’s Notes: Jane is willing to identify a concrete step: one structured break during work and one proactive communication attempt at home. She appears motivated yet still uncertain.

2:35 PM - 2:40 PM (Review of Mood & Safety)
	•	Therapist: “On a scale of 0-10, how would you rate your anxiety right now?”
	•	Client: “Maybe a 6. It was about an 8 earlier in the week.”
	•	Therapist: “Any thoughts of self-harm or harm to others since we last spoke?”
	•	Client: “No, I’ve had no suicidal thoughts. It’s just stress and worry, not that kind of feeling.”
	•	Therapist: “Okay, that’s good to know. Are you still taking your medication as prescribed by your psychiatrist?”
	•	Client: “Yes, I’ve been consistent with my SSRI. I think it helps a bit.”

Therapist’s Notes: Jane denies self-harm ideation. Anxiety rating is moderately high but lower than peak for the week.

2:40 PM - 2:45 PM (Session Wrap-Up & Next Steps)
	•	Therapist: “In our next session, we can check in on how the mid-morning breaks and the proactive communication attempt went. Let’s also consider practicing a brief relaxation exercise together next time.”
	•	Client: “That sounds good. I’ll try to be more consistent with those breaks and let you know how it goes.”
	•	Therapist: “Great. See you next week at the same time.”
	•	Client: “Thank you, see you then.”

Supplementary Data/Measures:
	•	PHQ-9: Administered at intake, last score was 9 (mild-moderate depression symptoms). Not administered this session but client reports stable mood with primarily anxiety-driven symptoms.
	•	GAD-7: Last recorded score was 12, suggesting moderate anxiety. Client’s subjective rating today is a 6/10 at session’s end.

No presence of family members noted this session. Client was alone in a private space.