Abdallah Evaluation Template [Blank plain-text template for basic EHR free-text fields. ASCII only - safe for legacy systems. Lines in square brackets are guidance - delete before saving. Adapt to your setting, payer and regulator.] 1. IDENTIFYING AND ADMINISTRATIVE DATA ------------------------------------------------------- Patient name: ______________________________ File / MRN (Medical Record Number): ______________________________ DOB (Date of Birth) / Age: ______________________________ Sex / Gender: ______________________________ Marital status / Dependents: ______________________________ Occupation: ______________________________ Nationality / Residence: ______________________________ Referral source and reason: ______________________________ Date(s) of assessment: ______________________________ Clinician (name, title, license no.): ______________________________ Informants: ______________________________ Consent: ______________________________ Clinician Dr Mahmoud, Presenting Beneficiary Male in his 30’s, single, employed, Saudi, follow up after ADHD and medication diagnosis, 2. CC (CHIEF COMPLAINT) - PATIENT'S VERBATIM WORDS ------------------------------------------------------- [Record verbatim, in quotation marks.] CC: ______________________________ 3. HPI (HISTORY OF PRESENT ILLNESS) ------------------------------------------------------- [Onset, course, duration; core symptoms; precipitants; severity and functional impact; risk-relevant content; treatments tried; pertinent negatives (mania, psychosis, panic).] 4. PSYCHIATRIC ROS (REVIEW OF SYSTEMS) ------------------------------------------------------- [Screen and record positive/negative for each domain.] - Depression: ______________________________ - Anxiety / Panic: ______________________________ - Mania / Hypomania: ______________________________ - Psychosis: ______________________________ - OCD (Obsessive-Compulsive Disorder): ______________________________ - Trauma / PTSD (Post-Traumatic Stress Disorder): ______________________________ - Eating: ______________________________ - Sleep: ______________________________ 5. PAST PSYCHIATRIC HX (HISTORY) ------------------------------------------------------- [Prior diagnoses; psychotherapy and medication trials with response/adherence; hospitalisations; ED (Emergency Department) contacts; past suicide attempts and NSSI (Non-Suicidal Self-Injury).] Summary: ______________________________ 6. SUBSTANCE USE HX ------------------------------------------------------- - EtOH (alcohol) - pattern, units/week, AUDIT-C (Alcohol Use Disorders Identification Test-Consumption) score: ______________________________ - Nicotine / vaping: ______________________________ - Caffeine: ______________________________ - Illicit substances / prescription misuse: ______________________________ - Past SUD (Substance Use Disorder) treatment: ______________________________ 7. PMHX (PAST MEDICAL HISTORY), MEDICATIONS AND ALLERGIES ------------------------------------------------------- PMHx: ______________________________ Current medications (incl. OTC (Over-The-Counter)): ______________________________ Allergies: ______________________________ Investigations requested / pending: ______________________________ 8. FHX (FAMILY HISTORY) ------------------------------------------------------- [Psychiatric illness, suicide, substance use, relevant medical conditions in first- and second-degree relatives.] Summary: ______________________________ 9. DEVELOPMENTAL AND SOCIAL HX ------------------------------------------------------- - Birth / development / childhood environment: ______________________________ - Education and occupational history: ______________________________ - Relationships and family: ______________________________ - Housing and finances: ______________________________ - Forensic / legal: ______________________________ - Trauma history: ______________________________ - Religion / spirituality: ______________________________ - Lifestyle and exercise: ______________________________ 10. MSE (MENTAL STATUS EXAMINATION) ------------------------------------------------------- - Appearance and Behaviour: ______________________________ - Speech: ______________________________ - Mood and Affect: ______________________________ - Perception: ______________________________ - Thought Content (incl. SI/HI (Suicidal/Homicidal Ideation)): ______________________________ - Thought Form / Process: ______________________________ - Cognition (incl. screen, e.g. MoCA (Montreal Cognitive Assessment)): ______________________________ - Insight: ______________________________ - Judgement: ______________________________ 11. MBC (MEASUREMENT-BASED CARE) - BASELINE SCORES ------------------------------------------------------- [Format: Measure: score - severity band - repeat cadence] - PHQ-9 (Patient Health Questionnaire-9): ______________________________ - GAD-7 (Generalised Anxiety Disorder-7): ______________________________ - WSAS (Work and Social Adjustment Scale): ______________________________ - ISI (Insomnia Severity Index): ______________________________ - Other (e.g. PCL-5 (PTSD Checklist for DSM-5), AUDIT-C): ______________________________ Reliable-change convention: a reduction of >=5 points on PHQ-9 or GAD-7 is treated as reliable improvement. 12. RISK ASSESSMENT ------------------------------------------------------- 12.1 C-SSRS (COLUMBIA-SUICIDE SEVERITY RATING SCALE) - SCREENER SUMMARY - Wish to be dead: ______________________________ - Non-specific active suicidal thoughts: ______________________________ - Ideation with method / intent / plan: ______________________________ - Suicidal behaviour (lifetime / past 3 months): ______________________________ 12.2 RISK AND PROTECTIVE FACTORS - Static factors: ______________________________ - Dynamic (modifiable) factors: ______________________________ - Protective factors: ______________________________ 12.3 RISK FORMULATION AND LEVEL [Synthesise: current level (low / moderate / high), rationale, risk to others, safeguarding, review interval and escalation criteria.] Formulation: ______________________________ 12.4 SPI (STANLEY-BROWN SAFETY PLANNING INTERVENTION) - 6 STEPS - Step 1 - Warning signs of an impending crisis: ______________________________ - Step 2 - Internal coping strategies: ______________________________ - Step 3 - Social contacts and settings that provide distraction: ______________________________ - Step 4 - Family members or friends who may help resolve a crisis: ______________________________ - Step 5 - Professionals and agencies to contact: ______________________________ - Step 6 - Making the environment safer (means-safety counselling): ______________________________ 13. BIOPSYCHOSOCIAL FORMULATION - 4PS ------------------------------------------------------- [4Ps = Predisposing, Precipitating, Perpetuating, Protective; each across Biological, Psychological and Social domains.] PREDISPOSING: The background, genetic, or historical background vulnerabilities (such as childhood trauma or family history) that made the person more susceptible - Biological: ______________________________ - Psychological: ______________________________ - Social: ______________________________ PRECIPITATING: The specific recent triggers, events, or life changes that caused the problem to surface or flare up at this specific time - Biological: ______________________________ - Psychological: ______________________________ - Social: ______________________________ PERPETUATING: The ongoing behaviors, thoughts, or environmental stressors (such as avoidance or poor coping mechanisms) that maintain the cycle and keep the problem going - Biological: ______________________________ - Psychological: ______________________________ - Social: ______________________________ PROTECTIVE: The personal strengths, positive coping skills, and social support systems that help build resilience and aid recovery - Biological: ______________________________ - Psychological: ______________________________ - Social: ______________________________ NARRATIVE SYNTHESIS: [Two to four sentences: how the factors interact to produce and maintain the presentation; identify the primary treatment targets (usually the perpetuating factors).] 14. CULTURAL FORMULATION - CFI (CULTURAL FORMULATION INTERVIEW, DSM-5-TR) ------------------------------------------------------- - Cultural definition of the problem: ______________________________ - Perceived causes, context and supports: ______________________________ - Self-coping and past help-seeking: ______________________________ - Current help-seeking preferences: ______________________________ 15. DIAGNOSIS - DSM-5-TR WITH ICD-10-CM CODES ------------------------------------------------------- [DSM-5-TR = Diagnostic and Statistical Manual of Mental Disorders, 5th ed., Text Revision; ICD-10-CM = International Classification of Diseases, 10th Revision, Clinical Modification.] - Principal diagnosis (code): ______________________________ - Comorbid diagnoses (codes): ______________________________ - Provisional / rule-outs and differentials: ______________________________ - Psychosocial stressor Z-codes: ______________________________ 16. TREATMENT PLAN ------------------------------------------------------- 16.1 PROBLEM LIST ______________________________ 16.2 SMART GOALS (SPECIFIC, MEASURABLE, ACHIEVABLE, RELEVANT, TIME-BOUND) - G1: ______________________________ - G2: ______________________________ - G3: ______________________________ 16.3 INTERVENTIONS - Psychological therapy (modality, dose, techniques): ______________________________ - Sleep / lifestyle: ______________________________ - Exercise prescription: ______________________________ - Pharmacotherapy pathway / referral (shared decision-making): ______________________________ - Family / systemic: ______________________________ - Liaison and referrals: ______________________________ 16.4 MBC SCHEDULE, SAFETY AND REVIEW - MBC schedule and reliable-change threshold: ______________________________ - Safety plan status and escalation criteria: ______________________________ - Review date: ______________________________ 17. CLINICIAN ATTESTATION ------------------------------------------------------- I confirm that this report reflects my clinical assessment on the date stated and that the patient was involved in decisions about the plan. Clinician name and title: ______________________________ Licence No.: ______________________________ Signature / Date: ______________________________ APPENDIX A - POST-SESSION PROGRESS NOTE (GIRP+ FORMAT) ------------------------------------------------------- [GIRP+ = Goal, Intervention, Response, Plan, extended with Data, MBC scores and an explicit Risk line every session. Golden thread: every note links to a treatment-plan goal.] Session no. / Date / Duration / Modality: ______________________________ G (Goal addressed - from treatment plan): ______________________________ D (Data - patient-reported and clinician-observed): ______________________________ I (Intervention - name the specific technique): ______________________________ R (Response to the intervention): ______________________________ A (Assessment - progress, interpretation, MBC scores and trend): ______________________________ Risk (SI/HI screen; safety plan status): ______________________________ P (Plan - next steps, homework, referrals, next appointment): ______________________________ 0-9079876968576865786576876986987 COMPREHENSIVE INITIAL PSYCHIATRIC AND CLINICAL PSYCHOLOGY EVALUATION WORKED EXAMPLE - FICTIONAL PATIENT (JOHN DOE). FOR TRAINING AND TEMPLATE USE ONLY; NOT A REAL PERSON OR CLINICAL RECORD. 1. IDENTIFYING AND ADMINISTRATIVE DATA -------------------------------------------------------- Patient name: John Doe (fictional) File / MRN (Medical Record Number): FT-2026-0142 DOB (Date of Birth) / Age: 12 March 1992 / 34 years Sex / Gender: Male Marital status / Dependents: Married; two children (ages 6 and 4) Occupation: Senior accountant, financial services Nationality / Residence: British expatriate; resident in Jeddah, KSA (Kingdom of Saudi Arabia) Referral source and reason: Self-referred on recommendation of GP (General Practitioner), Dr A. Smith - low mood and persistent worry Date(s) of assessment: 4 August 2026 (90-minute intake) Clinician: [Clinician name], Licensed Clinical Psychologist - SCFHS (Saudi Commission for Health Specialties) Licence No. 21-XXXXXXX Informants: Patient (primary); telephone collateral from spouse with written consent Consent: Written informed consent obtained for assessment, documentation, MBC (Measurement-Based Care) data collection and GP liaison; limits of confidentiality explained and understood 2. CC (CHIEF COMPLAINT) – PATIENT'S VERBATIM WORDS ---------------------------------------------------------------------------- "I can't switch off the worry any more, and lately I don't enjoy anything - not even the kids." 3. HPI (HISTORY OF PRESENT ILLNESS) -------------------------------------------------------------- Mr Doe presents with a six-month history of persistent low mood and anhedonia (loss of interest or pleasure), with marked deterioration over the past two months. Onset followed a company restructuring announcement in February 2026 carrying a credible threat of redundancy. Core depressive symptoms: depressed mood most of the day, nearly every day; anhedonia (has stopped weekly golf and most social contact); initial and middle insomnia (sleep-onset latency 60-90 minutes; two to three awakenings nightly); fatigue; reduced appetite with approximately 4 kg unintentional weight loss; impaired concentration affecting work output; evening psychomotor restlessness; and guilt-laden rumination ("I'm letting everyone down"). Concurrently he reports excessive, difficult-to-control worry across multiple domains (job security, finances, children's schooling, health), present more days than not for over six months, accompanied by muscle tension, irritability and easy fatigability - a pattern consistent with GAD (Generalised Anxiety Disorder) rather than worry confined to mood episodes. Occasional subthreshold autonomic surges occur without full panic attacks. Three weeks ago he experienced fleeting passive thoughts that his family "might be better off without the stress of him", without active SI (Suicidal Ideation), plan, intent or preparatory behaviour; none in the past week. He denies symptoms of mania/hypomania and psychosis. Self-management has included OTC (Over-The-Counter) melatonin with minimal benefit and increased caffeine; previously regular exercise ceased about four months ago. Functional impact includes presenteeism at work, withdrawal from family activities and growing marital tension. 4. PSYCHIATRIC ROS (REVIEW OF SYSTEMS) ------------------------------------------------------- - Depression: positive - syndromal major depressive episode (see HPI). - Anxiety / Panic: positive - GAD pattern; subthreshold panic sensations; no agoraphobic avoidance. - Mania / Hypomania: denied - no episodes of elevated mood, decreased need for sleep, grandiosity or risk-taking; MDQ (Mood Disorder Questionnaire) negative. - Psychosis: denied - no AH/VH (Auditory/Visual Hallucinations), delusions or disorganisation. - OCD (Obsessive-Compulsive Disorder): denied - no obsessions or compulsions. - Trauma / PTSD (Post-Traumatic Stress Disorder): denied - no Criterion-A exposure; no intrusions, avoidance or hyperarousal. - Eating: appetite reduced secondary to mood; no restriction, bingeing or compensatory behaviours. - Sleep: initial and middle insomnia about five nights/week; no OSA (Obstructive Sleep Apnoea) features - no snoring or witnessed apnoeas; BMI (Body Mass Index) 24.8. 5. PAST PSYCHIATRIC HX (HISTORY) ----------------------------------------------------------------- - One prior depressive episode at age 21 during final-year university examinations; treated with ten sessions of CBT (Cognitive Behavioural Therapy)-informed university counselling; full remission within about four months; no pharmacotherapy. - No psychiatric hospitalisations or ED (Emergency Department) contacts; no prior suicide attempts; no NSSI (Non-Suicidal Self-Injury); no prior psychotropic medication trials. 6. SUBSTANCE USE HX ----------------------------------------------------------------------------------- - EtOH (alcohol): four to six units/week over two to three occasions, no binge pattern; consumption reported as confined to travel outside the Kingdom; AUDIT-C (Alcohol Use Disorders Identification Test-Consumption) = 2 (low risk). - Nicotine: never smoker; no vaping. - Caffeine: about four cups of coffee daily, last cup around 18:00 - relevant to insomnia. - Illicit / prescription misuse: denied; no history of SUD (Substance Use Disorder) or treatment. 7. PMHX (PAST MEDICAL HISTORY), MEDICATIONS AND ALLERGIES ------------------------- PMHx: mild essential hypertension, diet-controlled - last BP (Blood Pressure) 128/82; no thyroid disease, head injury, seizures or chronic pain. Current medications: none regular; OTC melatonin 5 mg PRN (as required) at night. Allergies: NKDA (No Known Drug Allergies). Investigations: TFTs (Thyroid Function Tests), FBC (Full Blood Count), vitamin D and HbA1c (glycated haemoglobin) requested via GP - results pending. 8. FHX (FAMILY HISTORY) --------------------------------------------------------------------------------- - Mother: recurrent MDD (Major Depressive Disorder) with good response to an SSRI (Selective Serotonin Reuptake Inhibitor). - Maternal uncle: died by suicide when the patient was 15 (noted as a static risk factor). - Father: hypertension and T2DM (Type 2 Diabetes Mellitus). No family history of bipolar disorder or psychosis. 9. DEVELOPMENTAL AND SOCIAL HX ----------------------------------------------------------------- - Development: normal pregnancy, birth and milestones; eldest of three; describes a stable but achievement-focused upbringing; no childhood abuse or neglect reported. - Education / occupation: BSc Accounting and Finance; ACCA (Association of Chartered Certified Accountants)-qualified; nine years with current firm, promoted to senior accountant in 2022. - Relationships: married eight years - supportive though "strained lately"; two children with whom he is closely bonded. - Housing / finances / forensic / trauma: stable company-linked housing; anxiety centres on potential redundancy rather than current debt; forensic and legal history nil; no significant trauma history. - Religion / spirituality: attends a small expatriate church group irregularly; describes faith as a private source of comfort. - Lifestyle / exercise: previously gym three times weekly plus weekly golf; currently sedentary; diet adequate. 10. MSE (MENTAL STATUS EXAMINATION) ----------------------------------------------------------- - Appearance and Behaviour: appears stated age; casually dressed and adequately groomed; cooperative with good rapport; intermittent eye contact; mild psychomotor slowing with restless leg movement when discussing work. - Speech: normal rate, rhythm and volume; slightly increased response latency. - Mood and Affect: mood "worn down" (patient's words); affect restricted in range, congruent with mood, reactive when discussing his children; no lability. - Perception: no AH/VH; no depersonalisation or derealisation. - Thought Content: predominant worry themes (job, finances) with mild hopelessness and guilt-laden self-critical cognitions; no delusions, overvalued ideas or ideas of reference; denies current SI/HI (Suicidal/Homicidal Ideation); passive ideation three weeks ago as per HPI. - Thought Form / Process: linear, coherent and goal-directed; no circumstantiality, tangentiality or flight of ideas. - Cognition: alert, fully orientated; attention and registration grossly intact; MoCA (Montreal Cognitive Assessment) 28/30 (-1 delayed recall, -1 serial subtraction) - within normal limits in the context of poor sleep. - Insight: good - recognizes symptoms as depression and anxiety and is actively seeking treatment. - Judgement: intact - appropriate help-seeking; no risk-laden decision-making. 11. MBC (MEASUREMENT-BASED CARE) ------------------------------------------------------------- - BASELINE SCORES - PHQ-9 (Patient Health Questionnaire-9): 16/27 - moderately severe depression - repeat every session. - GAD-7 (Generalized Anxiety Disorder-7): 13/21 - moderate anxiety - repeat every session. - WSAS (Work and Social Adjustment Scale): 21/40 - significant functional impairment - repeat every 4 weeks. - ISI (Insomnia Severity Index): 15/28 - moderate clinical insomnia - repeat every 4 weeks. - AUDIT-C (alcohol screen): 2/12 - low risk - intake; repeat if indicated. Reliable-change convention: a reduction of >=5 points on PHQ-9 or GAD-7 is treated as reliable improvement. 12. RISK ASSESSMENT ------------------------------------------------------------------------------- 12.1 C-SSRS (COLUMBIA-SUICIDE SEVERITY RATING SCALE) - SCREENER SUMMARY - Wish to be dead: YES (transient, three weeks ago; none in the past week). - Non-specific active suicidal thoughts: NO. - Ideation with method, intent or plan: NO. - Suicidal behaviour (lifetime and past three months): NO. 12.2 RISK AND PROTECTIVE FACTORS - Static factors: male; family history of suicide (maternal uncle); prior depressive episode. - Dynamic factors: moderately severe depression; insomnia; occupational uncertainty; mild hopelessness; social withdrawal. - Protective factors: strong attachment to spouse and children; explicit reasons for living; active help-seeking and good engagement; no access to firearms; no substance misuse; retained future orientation. 12.3 RISK FORMULATION AND LEVEL Current suicide risk assessed as LOW: passive ideation only, resolved, with no plan, intent or behavior, and robust protective factors - against a background of low-to-moderate chronic vulnerability. Risk to others: nil identified. Safeguarding of dependents: no concerns; children well cared for. Risk to be reviewed at every session while ideation history remains recent. 12.4 SPI (STANLEY-BROWN SAFETY PLANNING INTERVENTION) - 6 STEPS - Step 1 - Warning signs: night-time rumination, "better off" thoughts, withdrawing to the home office. - Step 2 - Internal coping strategies: paced breathing; brief walk; scheduled worry period; shower - Step 3 - Social contacts and settings for distraction: telephone brother (UK); coffee with colleague M.; family park outing. - Step 4 - Family or friends who can help: disclose to spouse using the agreed phrase "having a heavy night". - Step 5 - Professionals and agencies: clinic line during business hours; nearest ED (Emergency Department); 937 MOH (Ministry of Health) health line. - Step 6 - Making the environment safer: household medications moved to a locked cabinet managed by spouse; no firearms in the home. Copy of the plan given to the patient; to be reviewed each session. 13. BIOPSYCHOSOCIAL FORMULATION - 4PS ------------------------------------------------------- PREDISPOSING: - Biological: family history of MDD and suicide; male, mid-30s. - Psychological: perfectionistic standards; self-worth contingent on achievement. - Social: expatriate status; distance from extended family. PRECIPITATING: - Biological: sleep disruption; high evening caffeine load. - Psychological: threat to professional identity and provider role. - Social: company restructuring; credible redundancy threat. PERPETUATING: - Biological: chronic insomnia; physical deconditioning. - Psychological: rumination; all-or-nothing appraisals; avoidance and withdrawal reducing positive reinforcement. - Social: reduced social contact; marital strain; presenteeism cycle. PROTECTIVE: - Biological: good general health; no substance misuse; prior full remission. - Psychological: psychological mindedness; positive prior therapy experience; intact insight. - Social: stable marriage; strong bond with children; secure housing; currently employed. NARRATIVE SYNTHESIS: The presentation is best understood as a recurrence of MDD with comorbid GAD in a man whose achievement-contingent self-worth was directly threatened by organisational restructuring. Insomnia, rumination, behavioural withdrawal and cessation of exercise now maintain the episode, while strong family attachment, insight and psychological mindedness are key treatment assets. Perpetuating factors are the primary treatment targets. 14. CULTURAL FORMULATION - CFI (CULTURAL FORMULATION INTERVIEW, DSM-5-TR) ------------------------------------------------------- - Cultural definition of the problem: frames his difficulties as "stress and burnout" rather than illness. - Perceived causes, context and supports: attributes onset to work; fears a diagnosis could become known within a small expatriate professional community (stigma); supports include spouse, church group and selected colleagues. - Self-coping and past help-seeking: values self-reliance ("just get on with it"); prior counselling was normalised through the university context. - Current help-seeking preferences: prefers structured talking therapy first; open to a medication review if progress stalls; assessment conducted in English with no clinician-patient linguistic or cultural barriers identified. 15. DIAGNOSIS - DSM-5-TR WITH ICD-10-CM CODES ---------------------------------------------- - Principal diagnosis: MDD, recurrent episode, moderate - F33.1. - Comorbid: GAD - F41.1. - Provisional: insomnia disorder - F51.01 (expected to remit with mood treatment; re-evaluate at review). - Differentials / rule-outs: adjustment disorder with mixed anxiety and depressed mood (excluded - full syndromal criteria met, duration over six months); hypothyroidism/anaemia (bloods pending); substance- or medication-induced mood disorder (excluded); bipolar spectrum (no history of hypomania/mania; MDQ negative). - Psychosocial stressor codes: Z56.2 threat of job loss; Z60.3 acculturation difficulty (mild - monitor). 16. TREATMENT PLAN ------------------------------------------------------------------------------------- 16.1 PROBLEM LIST 1) depressive episode; 2) generalised worry; 3) insomnia; 4) deconditioning and activity withdrawal; 5) occupational stress; 6) secondary marital strain. 16.2 SMART GOALS (SPECIFIC, MEASURABLE, ACHIEVABLE, RELEVANT, TIME-BOUND) - G1: Reduce PHQ-9 from 16 to <=9 by week 8 and <=4 (remission) by week 16. - G2: Reduce GAD-7 from 13 to <=7 by week 8. - G3: Sleep-onset latency under 30 minutes and no more than one awakening per night (sleep diary) by week 6. - G4: Graded return to exercise - two 30-minute sessions/week by week 3; three sessions/week plus weekly golf by week 6. - G5: One valued family activity per week from week 1. 16.3 INTERVENTIONS - Psychological: CBT, 12-16 weekly 50-minute sessions - BA (Behavioural Activation) with activity scheduling and graded task assignment in weeks 1-4; cognitive restructuring of catastrophic and all-or-nothing appraisals; scheduled "worry time", worry postponement and intolerance-of-uncertainty work for GAD; relapse-prevention blueprint in the final phase. - Sleep: CBT-I (Cognitive Behavioural Therapy for Insomnia) components - stimulus control and sleep-window restriction; caffeine curfew at 14:00; review ongoing need for melatonin. - Exercise prescription: individualised graded resistance plus Zone-2 aerobic programme delivered under dual clinical-S&C (Strength and Conditioning) governance; dosage progressed against ISI and PHQ-9 trends and integrated with BA targets. - Pharmacotherapy pathway (shared decision-making): patient prefers psychotherapy first. Agreed contingency: if PHQ-9 reduction is under 25-30% by session 6, referral to GP/psychiatrist to discuss SSRI initiation; written patient information provided. - Couple: one conjoint psychoeducation session offered and accepted for week 4. - Liaison: GP letter with consent - bloods and BP follow-up. 16.4 MBC SCHEDULE, SAFETY AND REVIEW - MBC schedule: PHQ-9 and GAD-7 every session (reliable change >=5 points); WSAS and ISI four-weekly; formal review at session 6 on 15 September 2026. - Safety: SPI in place and reviewed each session; escalation criteria documented - emergence of active SI, plan or intent triggers same-day risk review and psychiatry referral. - Documentation standard: progress notes written in open-notes-safe, person-first language and available to the patient on request; any private process notes stored separately; records handled per PDPL (Personal Data Protection Law, KSA) requirements for sensitive health data. 17. CLINICIAN ATTESTATION ---------------------------------------------------------------------------- I confirm that this report reflects my clinical assessment on the date stated and that the patient was involved in decisions about the plan. Clinician name and title: [Clinician name], Licensed Clinical Psychologist SCFHS Licence No.: 21-XXXXXXX Signature / Date: 4 August 2026 APPENDIX A - POST-SESSION PROGRESS NOTE (GIRP+ FORMAT) -------------------------------- GIRP+ = Goal, Intervention, Response, Plan, extended with Data, MBC scores and an explicit Risk line every session. Golden thread: every note links to a treatment-plan goal. Session no. / Date / Duration / Modality: Session 2 - 11 August 2026 - 50 minutes - in person G (Goal addressed): G1 and G4 - behavioural activation; re-establish structured exercise. D (Data - reported and observed): Reports completing four of six planned activities; mood rated 6/10 after a family park outing versus 3/10 baseline; sleep unchanged. Presented on time, brighter reactive affect, spontaneous speech. I (Intervention - named technique): Reviewed activity diary; graded task assignment; collaboratively scheduled week-2 activities including two 30-minute gym sessions; introduced cognitive restructuring with a thought-record demonstration on "I'm letting everyone down". R (Response): Engaged and completed in-session tasks; initially skeptical of thought records but agreed to a between-session trial. A (Assessment incl. MBC): Early behavioural engagement consistent with the expected trajectory. PHQ-9 = 14 (-2); GAD-7 = 12 (-1) - no reliable change yet (threshold >=5). Risk: Denies SI/HI; no passive ideation since intake; safety plan reviewed, unchanged. P (Plan): Continue BA; add a worry-postponement experiment; review sleep diary next session. Session 3: 18 August 2026.