Service
90837 · 60-min therapy
Modality
Telehealth
Risk level
Low
SOAP
SSubjective
Client reports continued depressed mood (5/10), sleep improved to 6 hrs, denies SI/HI. States medication started last week is 'helping a little'. Family stressors at work.
OObjective
Alert, oriented x3. Mood depressed, affect congruent. Speech regular rate/rhythm. Engaged in session. PHQ-9 today: 12 (down from 16 last week).
AAssessment
MDD recurrent, moderate. Partial response to sertraline 50mg. Risk: low. Continued therapy and med adherence indicated.
PPlan
Continue weekly individual therapy. Behavioral activation worksheet for next week. Refer to psychiatry for med review on Apr 30. Safety plan reviewed: parent + crisis line.
Goals progress
Reduce depressive symptoms (PHQ-9 < 5)55%
Sleep ≥ 7 hrs / night40%
Re-engage in social activities (1+/wk)70%