Subjective: James reports that he has been feeling down and has been struggling to concentrate. He states that he has been feeling fatigued and has been having difficulty sleeping. He reports that he has been feeling hopeless and has been having thoughts of self-harm.
Objective: James appears to be in a depressed mood. His speech is slow and his body posture is slumped. He has poor eye contact and his attitude is apathetic. He is fully orientated and his language skills are intact.
Assessment: James appears to be suffering from major depressive disorder. His symptoms are severe and interfere with his day-to-day functioning.
Plan: 1. Meet with James again in 2 days, Friday, 20th May
2. James to follow his safety plan if required
3. James to make his family aware of his current state of mind
4. Referral to a mental health professional for further assessment and treatment