Note Examples
Example Intake

Example Intake

Session Title: Initial Assessment to Explore Anxiety Symptoms and Challenges

Brief Summary Of Session: The client presented with anxiety symptoms that have been ongoing for 7-8 years, including panic attacks, health-related fears, and social anxiety. She described difficulty publicly speaking, discomfort in groups, obsessive thoughts, and impairments in work, school, and relationships. The therapist conducted a clinical interview, gathered background information, made initial diagnoses of generalized anxiety disorder with panic, and developed a preliminary treatment plan involving CBT, compassion focused therapy, EMDR, and polyvagal theory approaches. Coping strategies like meditation were also discussed.

Consent: The therapist reviewed confidentiality, limits of confidentiality around harm to self or others, payment procedures, and the client's rights. The client seemed to understand and agree to informed consent, asking clarifying questions. Proper informed consent procedures appear to have been followed.

  • Quote (Consent): “I feel comfortable proceeding with treatment."

Presentation

  • Chief Complaint: The client presented with ongoing anxiety symptoms that she feels are getting worse, including panic attacks, health-related fears, social anxiety and discomfort being in groups. She described anxiety being very prominent in her life for the past 7-8 years.
    • Quote (Chief Complaint): “My anxiety feels like a dark cloud over me every single day, making it hard to function or find joy in life.”
  • Impairments And Challenges: The client's anxiety causes impairments in work, school, parenting, relationships, and social functioning. She has panic attacks during public speaking, group meetings at work, and in other anxiety-provoking situations. This affects her ability to focus, think clearly, and contribute effectively. She has withdrawn socially and become more quiet around groups due to social anxiety. Her anxiety also affects relationships with family members and her boyfriend. She struggles to manage anxiety symptoms during stressful situations.
    • Quote (Impairments And Challenges): “Whenever I feel anxious at work, it’s like my mind goes blank and I can’t get anything done. It’s so frustrating and makes me dread going to meetings.

Psychological Factors:

  • Family Mental Health History:The client did not disclose any significant family mental health history.
  • Previous Mental Health Treatments:The client saw a therapist previously for about a year and a half who provided hypnotherapy to help her take medications she had developed a phobia towards. She felt she was not getting what she wanted from that therapy.
  • Previous Mental Health Assessments: No previous diagnostic testing or psychological assessments were noted.
  • Symptom 1:
    • Symptom Description: Panic attacks
    • Onset: First panic attack occurred around age 18.
    • Frequency: Used to occur about once per week, now less frequent (last one was 6 months ago).
    • Ascendance: Panic attacks are becoming much less frequent than they used to be.
    • Intensity: Described panic attacks as very severe when they do occur.
    • Duration: Panic attacks have been present on and off for about 7-8 years.
    • Quote (Symptom): “During a panic attack it feels like I’m dying - my heart races, I sweat, and I lose control completely."
  • Symptom 2:
    • Symptom Description: Health-related anxiety
    • Onset: Started around age 18 after a negative experience taking a new medication.
    • Frequency: Occurs frequently when she has medical appointments, takes medication, or notices physical symptoms.
    • Ascendance: No improvement described.
    • Intensity: Described health-related anxiety as very severe.
    • Duration: Present for around 7-8 years.
    • Quote (Symptom): "Whenever I have a doctor's appointment I obsess for days beforehand about all the worst case scenarios."
  • Symptom 3:
    • Symptom Description: Social anxiety
    • Onset: Started more recently in the past 1-2 years. Did not have it previously.
    • Frequency: Occurs frequently when in groups or social situations.
    • Ascendance: No improvement described, feels it has gotten worse.
    • Intensity: Described social anxiety as severe and very uncomfortable when it occurs.
    • Duration: Present for around 1-2 years.
    • Quote (Symptom): "Being in a big crowd makes me want to crawl out of my skin - it's complete torture."
  • Symptom 4:
    • Symptom Description: Depressed mood
    • Onset: Started in the past year.
    • Frequency: Described as frequent over the past year.
    • Ascendance: No improvement described.
    • Intensity: Did not specify severity.
    • Duration: Present for around 1 year.
    • Quote (Symptom): "This heaviness and sadness comes over me and it's hard to remember what it feels like to be light and happy."

Biological Factors:

  • Medications: No medications reported.
  • Allergies: No allergies reported.
  • Family Medical History: No significant family medical history provided.
  • Medical Conditions: The client believes she may have high blood pressure which she associates with anxiety. No other medical conditions reported.
  • Sleep: No sleep issues reported.
  • Nutrition: No nutrition issues reported.
  • Physical Activity: No details provided about current physical activity.
  • Sexual Activity: No sexual health issues reported.
  • Substances: The client reported experimenting with drugs during college, including an instance where she had a severe panic attack after taking an unspecified drug. No current or regular substance use reported.

Social Factors

  • Work Or School: The client works in insurance sales on a team of all men. She has struggled to find satisfying work since graduating college and has changed jobs frequently. She is uncertain she likes her current job and lacks passion for it. She feels like she has to monitor her behavior around male coworkers.
  • Relationships: The client lives at home and has been with her boyfriend for 1.5 years. She describes some challenges due to his mood swings but feels generally happy. She feels she has suppressed her personality to avoid conflict. Family relationships are close and supportive.
  • Recreation: No recreational activities reported.
  • Family Social History: The client described a close family growing up and positive friendships. Had a rebellious period as a teenager due to strict parents. She now has a good relationship with her parents again.
  • Other Relevant Social Factors: No other relevant social factors noted.
  • Traumatic Experiences: The client reported losing a close friend at age 18 which affected her, but she did not describe lasting trauma symptoms from this loss. No other traumatic experiences explicitly mentioned.
  • Quote (Traumatic Experiences): "Although losing my friend affected me deeply, I was able to get through the grieving process and don't feel traumatized presently."

Clinical Assessment:

  • Clinical Conceptualization: The client appears to have developed generalized anxiety disorder with panic attacks following some early losses traumas around age 18. Her tendency to avoid and mask symptoms has perpetuated the anxiety, while trying to overly control her life has caused impairments. There are signs of comorbid depression emerging in the past year, likely due to chronic anxiety. Social and performance anxiety also appear tied to hypervigilance and poor distress tolerance.
  • Diagnosis 1:
    • Diagnosis Description: Generalized Anxiety Disorder
    • DSM-5 Code: 300.02
    • ICD-10 Code: F41.1
    • Reasoning: The client exhibits excessive anxiety and worry across multiple domains that is difficult to control. This includes restlessness, fatigue, concentration issues, muscle tension and sleep disturbance. Symptoms have persisted longer than 6 months and cause significant distress or impairment.
  • Diagnosis 2:
    • Diagnosis Description: Panic Disorder
    • DSM-5 Code: 300.01
    • ICD-10 Code: F41.0
    • Reasoning: The client has experienced recurrent, unexpected panic attacks followed by at least 1 month of persistent concern about additional attacks or maladaptive changes in behavior related to the attacks.
  • Comorbidity: The client likely has comorbid social anxiety disorder given her severe anxiety and avoidance of social situations and public speaking. Depressive disorder is also a probable comorbidity based on her descriptions of depressed mood, low motivation, and feelings of worthlessness in the past year. The comorbid disorders appear to mutually reinforce each other, exacerbating the client's impairment and symptoms.
  • Assessment Tool: Clinical Interview
  • Results: Read conceptualization
  • Status: Additional diagnostic assessments may be warranted to confirm diagnoses and inform treatment planning.

Mental Status Exam:

  • Mood And Affect: Anxious mood, affect is congruent.
  • Speech And Language: Speech is clear, coherent, and normal in rate and tone.
  • Thought Process And Content: Thought process is logical and goal-directed. Thought content is focused on her anxiety and panic symptoms. No evidence of delusions or obsessions.
  • Orientation: Oriented to person, place, and time.
  • Perceptual Disturbances: No perceptual disturbances reported or observed.
  • Cognition: Cognition appears intact based on interview.
  • Insight: Demonstrates insight into her diagnosis and need for treatment.
  • Risk Assessment:
  • Risks Or Safety Concerns: No safety concerns or risks were reported, stated, implied, or observed during the session.
  • Hopelessness: No statements indicating hopelessness were reported, stated, implied, or observed during the session.
  • Suicidal Thoughts Or Attempts : No suicidal thoughts, plans or intent were reported, stated, implied or observed during the session.
  • Self Harm: No self harming behaviors were reported, stated, implied or observed during the session.
  • Dangerous To Others: The client did not appear to pose any danger to others. No threats or violence were reported, stated, implied or observed during the session.
  • Quote (Risk): "I am not having any thoughts of hurting myself or others. I feel safe and stable at this time."
    Safety Plan: No safety plan was indicated or developed during this initial session.

Strengths And Resources:

  • Internal Strengths: The client demonstrated self-awareness and willingness to seek help. She has motivation to overcome her anxiety struggles.
  • External Resources: The client reported having close family relationships and a supportive boyfriend to provide resources.
  • Quote (Resources): "I'm ready to put in the hard work to get better - I know I have strengths that will help me through this process."

Interventions

  • Therapeutic Approach Or Modality: Cognitive behavioral therapy, compassion focused therapy, and EMDR approaches were proposed as appropriate modalities to address the client's anxiety.
  • Psychological Interventions:
  • Clinical interview to gather background information
  • Psychoeducation about anxiety disorders
  • Introduction of possible treatment approaches
  • Discussion of confidentiality and informed consent
  • Rationale: An initial clinical interview and assessment was conducted to build rapport, gather information to formulate an initial diagnostic impression and treatment plan, ensure proper informed consent procedures, and introduce the client to potential therapeutic approaches.

Progress And Response

  • Response To Treatment: This was an initial intake session, so no formal treatment has started yet. The client seemed open and responsive during the interview process.
  • Specific Examples Or Instances: The client asked questions to understand more about the process.
  • Quote (Progress): "I feel better just coming in today."
  • Challenges To Progress: No concerns about progress were noted as treatment has not yet begun.
  • Therapist Observations And Reflections: The therapist observed that the client exhibits significant anxiety affecting multiple areas of functioning. She lacks coping skills to manage anxiety effectively. Initial rapport was established during this intake session.
  • Therapeutic Alliance: Strong initial rapport established. No alliance issues noted.

Discussed Goals:

  • Goal 1:
    • Goal Description: Better understand and manage anxiety symptoms.
    • Metrics: Reduce panic attack frequency and self-reported anxiety levels.
    • Attainability: Attainable with client motivation and consistent practice of CBT and mindfulness techniques.
    • Relevance: Highly relevant to improving client's quality of life and functioning.
    • Timeframe: Expect regular progress over 8-12 weeks.
    • Quote (Goal): “The anxiety has such a grip on my life right now. I’ll know I’m better when I break free from its constant presence.”
  • Goal 2:
    • Goal Description: Improve ability to speak up for needs and set boundaries.
    • Metrics: Increase assertive responses during role plays and real-life situations. Reduce people-pleasing behaviors.
    • Attainability: Attainable through self-compassion exercises, assertiveness training and cognitive restructuring.
    • Relevance: Important for managing anxiety, improving relationships and boosting self-esteem.
    • Timeframe: Expect gradual improvement over 8-12 weeks.
    • Quote (Goal): “I put too much pressure on myself to make others happy all the time. I need to learn how to put my needs first.”
  • Barriers To Achieving Goals: Lack of self-compassion, low distress tolerance, and avoidance behaviors may hinder progress if not addressed. Social anxiety also makes it difficult for her to speak up.

Follow Up Actions And Plans :

  • Homework: Complete initial assessments sent by the therapist and schedule next appointment.
  • Plan For Future Session: Begin compassion focused therapy treatment plan, start Safe and Sound Protocol, and continue gathering assessment data.
  • Plans For Continued Treatment: Schedule weekly 50-minute sessions, with a week off in between, for 8-12 weeks initially.
  • Coordination Of Care: No other providers involved currently. The therapist may coordinate with client's PCP in the future regarding anxiety treatment.