Signed & locked
AI draftdrafted by LumenYour editsadded or revised by you
S
Subjective
AI draft — uneditedClient reported heightened anxiety this week tied to work deadlines, rated 7/10. Two brief panic episodes; sleep improved using diaphragmatic breathing. Denies SI/HI.
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Objective
AI draft — uneditedPresented mildly anxious, engaged, oriented x4. Affect congruent, full range. No psychomotor agitation.
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Assessment
AI draft — uneditedGAD, moderate. Responding to CBT; continued gains in cognitive restructuring. Functioning stable.
P
Plan
AI draft — uneditedContinue weekly CBT. Assign thought-record homework. Begin exposure hierarchy next session. RTC 1 week.
Dr. Maya Okafor, PsyD
Electronically signed May 26, 2026 at 11:00 AM · v2 locked · audio deleted
Lumen never suggests diagnoses. Assessment language and clinical judgment always come from the signing clinician.