Training-only MSE. For educational and supervision purposes.
Created: 03 Jul 2026, 14:40
Student: Juliet
Batch: June 2026
Client / Case Name: Sarah
Date of assessment: 03/07/2026
Sickly, Perplexed
Retardation
Cooperative
Responsive, alert but slow
Rate slow
Mood - Fearful and anxious Affect - Flat Reactivity - Slow
a. Thought Process:
Racing thoughts
b. Thought Content:
Negative automatic thoughts with no mention of self harm or harming others.
Delusional (Client frequently wakes up around 3 AM, unable to quiet racing thoughts about her professional performance and hypothetical future failures.)
Orientation: Overwhelmed, not focused to respond. Attention and concentration; Non attentive due to racing thoughts, concentration low. Memory: Remote Intelligence: Smart at work, bizarre thinking bizarre due to lack of sleep and racing thoughts Constructional Ability: The counsellor noted a flat affect, psychomotor retardation, and tearfulness when discussing her inability to "be happy" despite her professional success. A HAMS evaluation, neuro assessment and psycho-medical evaluation will be helpful in determing constructional ability.
Personal-Client is couragious to address her issues and seeked help. Knows has issues that is affecting her physically and emotionally. Social-Currently living in isolation, avoiding social circle, apprehensive about stuttering in front of team. Showing signs of social disorder. Test: Depression Test, Neurological Evaluation, Medical Evaluation required.
Grade IV. Awareness due to something unknown in self - Client can't name, has feelings of confusion and lack of control.
Psychomotor Retardation Assessment recommended. Neurological Assessment recommended.
Short title / summary: Depression and Social Disorder
An assessment based on the symptom of the possibility of Social Anhedonia: Lacking interest in social situations. Finding no pleasure in interacting with people. Loss of Interest: Dropping favorite activities and hobbies, Social Withdrawal: Avoiding friends, colleagues.