Ugonna Mbaegbu

Z enith Mental Wellness Centre -Ph:- DAP NOTES SESSION SUMMARY PATIENT INFORMATION Jane Doe Provider/Clinician’s Name Dr. Todd L. Grande Date of Birth (DOB) March 14, 1985 Gender Female Contact Number (555) 123 – 4567 Email - Appointment Date/Time August 15, 2025 – 10:00 AM Reason for Visit Follow-up consultation – weight management and binge eating concerns DATA eg b u U go n na Patient Name ba Patient reports no improvement since the last visit. Reports multiple binge eating episodes over the past week following consumption of brownies baked with her son, who had a minor head injury. Bingeing is intensified by the consumption of hamburgers, French fries, and candy. She described the episodes as “disgusting” and stated, “It’s like slavery, food owns me.” She expressed disgust, saying the clothes no longer fit. M Rates the importance of change at 10/10 but confidence to change at 0/10, Past success: Reports one prior behavioral success, which is stopping nail-biting. Perceives managing food intake as more challenging due availability.Identifies chocolate as a primary, non-negotiable trigger. to its constant Mood appears discouraged, Discouraged; affect is congruent. Speech is clear and coherent. No acute distress note. Z enith Mental Wellness Centre -Ph:- ASSESSMENT go n na ●​ Possible depressive features linked to hopeless statements. ●​ Binge eating disorder due to environmental factors.. ●​ Willingness to attempt small, manageable changes, such as eliminating Skittles for a set period. ●​ Low self-esteem and Low self-efficacy. ●​ Ready to begin exploring solutions, but may need additional support in overcoming emotional eating PLAN ●​ ●​ ●​ ●​ eg b u U Begin journaling to identify emotional triggers for binge eating. Initiate CBT for emotional eating Develop a healthy relationship with food and reduce binge eating episodes. Achieve gradual weight loss through balanced nutrition and consistent physical activity. ●​ Regular check-ins every 4 weeks to assess emotional eating patterns and weight loss progress.​ M ba PROVIDER’S SIGNATURE: DR. TODD L. GRANDE DATE: 08/10/2025