Putting it all together

Integrate screening results, your clinical information and further information required.
This section will then summarise:
1. Presenting concerns (e.g., EPDS of 15, reports low mood and appears anxious)
2. Relevant history (e.g., previous mental health difficulties)
2. Current stressors and triggers (e.g., unsettled baby, difficulty adjusting to first time motherhood)
3. Maintaining factors – what’s keeping them stuck (e.g., limited support, conflict in spousal relationship).
4. Protective factors – strengths (e.g., appears to have good bond with baby, reports close relationship with mother)
5. Major difficulties to be addressed (e.g., further assessment of depression)