Subjective:

Sam reported feeling sad and emotionally distressed during today’s session. He shared that he has been experiencing consistent feelings of sadness and hopelessness for the past few weeks. Sam also disclosed that he is currently homeless, which contributes to his overall distress and exacerbates his negative emotions.

Objective:

During the session, Sam appeared visibly downtrodden, with a flat affect and low energy. He displayed signs of tearfulness and maintained a slouched posture throughout the session. Sam reported difficulty sleeping and appetite changes, as well as decreased motivation to engage in daily activities. He expressed feelings of isolation and a lack of social support due to his current housing situation.

Assessment:

Based on the information shared, it appears that Sam is experiencing symptoms consistent with major depressive disorder. The presence of persistent sadness, hopelessness, sleep disturbances, appetite changes, and decreased motivation indicate a significant impact on Sam’s overall functioning. Additionally, being homeless adds an extra layer of stress and exacerbates his emotional distress.

Plan:

1. Safety assessment: Given the severity of Sam’s symptoms and his disclosure of feeling emotionally distressed, it is crucial to evaluate his current risk of self-harm or suicide. A safety plan will be developed collaboratively to ensure his well-being.

2. Psychoeducation: I will provide psychoeducation to Sam about depression, its symptoms, and the impact of homelessness on mental health. This will help him gain a better understanding of his experiences and provide a foundation for future interventions.

3. Establish a therapeutic alliance: Building a strong therapeutic relationship with Sam will be a priority. This will involve actively listening, empathizing, and validating his emotions and experiences. It is essential to create a safe and non-judgmental space where Sam feels comfortable sharing his thoughts and feelings.

4. Explore coping strategies: Together, we will explore various coping strategies that can help Sam manage his depressive symptoms and improve his overall well-being. This may include engaging in self-care activities, seeking social support, and exploring potential resources for stable housing.

5. Referral for housing support: Given Sam’s homelessness, it will be necessary to provide him with appropriate resources and referrals to organizations that specialize in assisting individuals experiencing housing instability. This will help address the underlying stressor and potentially alleviate some of the emotional distress.

6. Regular follow-up: Sam will be scheduled for regular follow-up sessions to monitor his progress and adjust the treatment plan accordingly. It will be important to assess the effectiveness of the interventions implemented and make any necessary modifications to support Sam’s recovery.

Note: This progress note reflects a fictional case and is solely for illustrative purposes. A real progress note would contain more detailed and specific information about the client, interventions, and progress over time.