LocalScribe

Demographics

The client presented for an intake evaluation. The client reported living with a partner and described current support in the home.

Presenting Problem

The client is seeking therapy for panic episodes, insomnia, and work stress following a role change approximately three months ago. Additional reported symptoms included chest tightness, racing thoughts, and avoidance of driving on the highway.

History

Personal/Social History

The client reported that anxiety symptoms have affected day-to-day functioning and stated that they called out from work twice during the current month. The client also described support from a partner.

Psychiatric History

The client reported prior therapy during college. The client denied suicidal or homicidal ideation.

Mental Status Examination

Current mental status information in the provided material is limited. The client reported panic symptoms, insomnia, racing thoughts, and anxiety-related avoidance of highway driving. No suicidal or homicidal ideation was reported. Additional clinician-observed findings for appearance, speech, affect, thought process, orientation, memory, insight, and judgment were not documented in the provided information.

Assessment

Initial assessment data suggest clinically significant anxiety symptoms with associated functional impairment in work and driving-related situations. PHQ-9 score of 13 is consistent with moderate depressive symptom severity, and GAD-7 score of 15 is consistent with severe anxiety symptom severity. These screening results provide additional context for the client's reported panic symptoms, insomnia, and current stress burden.

Recommendations

• Begin ongoing outpatient therapy focused on anxiety, panic symptoms, and stress-related functioning.
• Monitor panic frequency, sleep disturbance, and work-related impairment over the early phase of treatment.
• Continue using structured symptom measures as clinically indicated to track change over time.

Presenting Problems

The client presents with generalized anxiety with panic symptoms, anxiety-related avoidance of highway driving, reduced sleep, and work impairment in the context of a recent promotion and increased job stress. Current symptoms include panic episodes occurring approximately 3 to 4 times per week, catastrophic thinking, and decreased occupational functioning.

Goals and Objectives

• Goal 1: Reduce panic symptom frequency and intensity by 8/1/26.
  • Objective 1.1: Client will track panic episodes weekly and reduce frequency from 3 to 4 episodes per week to no more than 1 episode per week by 8/1/26.
  • Objective 1.2: Client will use paced breathing and grounding in at least 80% of panic episodes, as measured by self-report and session review, by 6/15/26.
• Goal 2: Increase ability to tolerate anxiety triggers related to commuting and work stress by 8/1/26.
  • Objective 2.1: Client will identify and challenge catastrophic thoughts linked to commute and supervisor-contact triggers in session and homework exercises by 6/1/26.
  • Objective 2.2: Client will complete graduated highway-driving exposure steps and report progress toward resuming highway driving by 8/1/26.
• Goal 3: Improve sleep and work attendance by 8/1/26.
  • Objective 3.1: Client will report sleep duration closer to 6 to 7 hours on most nights by 8/1/26.
  • Objective 3.2: Client will reduce anxiety-related work call-outs and improve consistency of attendance over the treatment period.

Interventions

Treatment will use a CBT framework to identify triggers, thoughts, physiological reactions, and avoidance patterns linked to panic and generalized anxiety symptoms. Interventions will include psychoeducation on the CBT model, cognitive restructuring for catastrophic thoughts, reinforcement of paced breathing and grounding strategies, and graduated exposure planning for highway driving and other anxiety triggers.

Frequency and Duration

The client will participate in weekly psychotherapy sessions for 12 weeks from 5/1/26 through 8/1/26, with progress reviewed during the treatment period.

Evaluation and Discharge Criteria

Progress will be evaluated through client report of panic frequency, driving avoidance, sleep, and work attendance, along with review of coping-skill use and symptom measures as clinically indicated. Treatment goals will be considered met when panic symptoms are reduced, catastrophic thinking is more effectively challenged, highway-driving avoidance has decreased, and functioning at work and sleep are improved to a clinically meaningful degree.