Training-only MSE. For educational and supervision purposes.
Created: 03 Jul 2026, 21:29
Student: Nitika Kashyap
Batch: June-july26
Client / Case Name: Maya
Date of assessment: 03-07-26
Neat, well-groomed, and dressed appropriately in standard student attire
Normal to slightly elevated tension due to fatigue; no psychomotor retardation noted.
Cooperative, highly collaborative, open, appreciative, and responsive to therapeutic tasks.
Clear and fully alert, though reporting subjective feelings of being "very tired".
Coherent, relevant, spontaneous, with normal rate and volume, expressing clear emotional nuances via text/interaction.
Mood is anxious and fatigued; affect is congruent with thought content, showing marked relief and improved confidence following successful application of exercises.
a. Thought Process:
Logical and coherent. The client responds directly to clinical prompts, explains her entire day sequentially (school, transit, coaching, dinner, and study blocks), and clearly articulates cause-and-effect regarding her habits. No signs of loose associations, circumstantiality, or flight of ideas.
b. Thought Content:
Overvalued ideas concerning academic perfection and test results. Marked by cognitive distortion and anxious preoccupation over underperforming in Physics. No evidence of delusions, obsessions, phobias, compulsions, suicidal ideation, or homicidal intent.
No evidence of hallucinations, illusions, depersonalization, or derealization.
Orientation: Intact. The client demonstrates clear orientation to time and schedule (recalling specific daily time slots like 8:00 AM to 3:00 PM and 5:15 PM to 8:00 PM). Attention & Concentration: Slightly compromised by chronic exhaustion but functionally intact. She demonstrates an ability to implement focused strategies successfully (e.g., reported feeling "focused" after utilizing the Blue Dot technique during her exam). Memory: Intact. Immediate, recent, and remote memory are preserved. She successfully recalls her test scores (19 out of 180 marks).
Personal & Social Judgment: Intact. She makes rational choices regarding seeking help, openly acknowledges the flaws in her unguided study schedules, and expresses a realistic need to modify her behavior to protect her health.
Grade VI : Excellent insight. The client completely recognizes that she has a problem with schedule formulation, connects her late-night habits to her severe physical exhaustion, and shows direct willingness to follow through with behavioral changes suggested by the therapist.
Language assessment: Normal; demonstrates clear, expressive use of communication via conversational text. Psychomotor abnormalities: None noted (absence of catatonia, tics, or severe psychomotor retardation).
Short title / summary: Anxious mood, physical fatigue, intact cognitive functions, and excellent clinical insight.
The client displays excellent prognosis due to high compliance, strong self-reflective capacities, and prompt therapeutic benefit from grounding and relaxation exercises.