NDIS Capacity Building Therapy Session Note

Participant Details

• Name: Liam O'Connor
• DOB: 14/05/1998 (26 yo)
• NDIS Number: 430-891-204
• Primary Diagnosis: Autism Spectrum Disorder (ASD) Level 2, Generalised Anxiety Disorder (GAD)

Therapist Details

• Name: Dr Sarah Jenkins
• Designation: Clinical Psychologist (AHPRA: PSY0001849201)
• Contact: s.jenkins@metropsych.com.au | (02) 9555 0192

Session Overview

Session focused on emotional regulation and graded exposure for community access. Reviewed homework from previous fortnight (using the SUDS scale during public transport trips). Utilised Cognitive Behavioural Therapy (CBT) framework to challenge catastrophic thinking regarding crowded spaces. Practised progressive muscle relaxation (PMR) and box breathing in-room to manage somatic anxiety symptoms.

Progress Towards NDIS Goals

• Goal 1: Increase independence in accessing the community, including using public transport independently.
  • Achievements: Successfully caught the local bus to the shopping centre twice this week with a support worker following in a car, down from requiring the support worker seated next to him.
  • Difficulties: Experienced high anxiety (SUDS 8/10) when the bus became crowded on Tuesday; exited one stop early.
• Goal 2: Develop strategies to manage anxiety and regulate emotions in daily life.
  • Achievements: Identified early physiological warning signs of sensory overload (tachycardia, jaw clenching) and applied noise-cancelling headphones promptly.
  • Plan Changes: Adjusted exposure hierarchy to focus on off-peak travel times for the next two weeks before re-attempting peak hour transit.

Participant's Feedback

Liam reported feeling frustrated that he had to exit the bus early on Tuesday, stating he felt like he "failed." However, after cognitive restructuring, he acknowledged that staying on the bus for three stops while distressed was an improvement. Expressed preference for visual schedules to track his exposure homework.

Therapist's Observations

Liam presented as well-groomed, alert, and oriented. Maintained intermittent eye contact (consistent with baseline). Affect was initially restricted and anxious when discussing the bus incident, shifting to euthymic and engaged when problem-solving. Demonstrated good insight into his sensory triggers and engaged well with the PMR exercise, noting a reduction in shoulder tension post-exercise.

Recommendations and Next Steps

• Homework: Complete 3x off-peak bus trips (between 10:00 and 14:00) over the next fortnight. Log SUDS ratings pre-, mid-, and post-trip using the provided visual tracking sheet.
• Daily Practice: Practise PMR once daily before bed using the guided audio track.
• Next Session: Scheduled for 28/03/2025 at 14:00. Will review exposure logs and introduce sensory grounding techniques (5-4-3-2-1 method).

Session Duration

• Date: 14/03/2025
• Start Time: 14:00
• End Time: 14:50
• Total Duration: 50 minutes ( plus 10 minutes non-face-to-face clinical documentation)

Therapist's Signature

Dr Sarah Jenkins Clinical Psychologist Date: 14/03/2025 15:05 AEDT