AI DAP Notes for Behavioral Health Specialists Using Opus

DATA: Client attended scheduled 50-minute individual therapy session. Presented with continued symptoms of depression including low mood 4/7 days this week (down from 6/7 last week), decreased motivation for household tasks, and sleep difficulties (averaging 6 hours, waking 2x nightly). Reports medication compliance with current regimen. Discussed recent conflict with family member that triggered feelings of rejection and worthlessness. Client became tearful when discussing childhood experiences of feeling "not good enough." PHQ-9 score: 15 (moderate depression, down from 18 at intake). Reports successful completion of behavioral activation homework - attended one social event as planned. ASSESSMENT: Client showing gradual improvement in depressive symptoms over past month. PHQ-9 decreased from 18 (moderately severe) to 15 (moderate), suggesting positive treatment response. Continues to struggle with interpersonal sensitivity and rejection fears, which appear rooted in early attachment experiences. Core belief of "I'm not good enough" identified as treatment target. Insight improving - client making connections between childhood experiences and current relationship patterns. Motivation for change present as evidenced by homework completion. Risk remains low with no suicidal ideation. PLAN: 1. Continue weekly individual therapy with CBT focus 2. Next session: Begin cognitive restructuring work on core belief "I'm not good enough" 3. Assign mood tracking homework using provided worksheet 4. Continue behavioral activation - assign 2 pleasant activities for this week 5. Review medication efficacy with psychiatrist at scheduled appointment next week 6. Return in 1 week