Note Examples
Example Intake

Example Intake

Session Title: Initial Couples Therapy Intake for Married Couple
Brief Summary Of Session: This was the initial intake session for a heterosexual married couple in their late 20s presenting with communication issues and marital conflicts. The clients described poor communication, frequent arguments, and difficulty resolving disagreements. Goals were set to improve communication and conflict resolution skills. CBT and Gottman interventions were introduced. Rapport was established with both clients who were engaged and motivated for therapy.

Consent: Therapist reviewed confidentiality, limits to confidentiality, and fees. Clients signed informed consent forms indicating understanding of policies. Both clients appeared to fully comprehend the consent process.

  • Quote (Consent): “We understand you have to report any abuse.”

Presentation:

  • Chief Complaint: Couple presented with complaints of poor communication, frequent arguments, and difficulty resolving marital conflicts. Report increased relationship dissatisfaction over the past year since getting married.
    • Quote (Chief Complaint): "We fight all the time lately over small things. I feel like he never listens to me." -Wife
  • Impairments And Challenges: Frequent arguing is causing distress in the relationship. The clients report decreased satisfaction, intimacy and time spent together. Work and social life have not yet been impacted although clients report constant relationship tension and arguments at home.
    • Quote (Impairments And Challenges): "The constant arguing at home is exhausting." - Husband
  • Communication Patterns: Couple describes poor communication marked by frequent misunderstandings, talking over each other, and difficulty listening. The wife reports feeling unheard while the husband reports feeling criticized.
    • Quote (Communication Patterns): "She always criticizes me when I try to explain my side." - Husband
  • Conflict Resolution: Clients report frequent heated arguments that escalate quickly. Neither partner expresses skills in de-escalation or conflict resolution. Disagreements often end unresolved.
    • Quote (Conflict Resolution): "Our fights just go round and round in circles until I give up." - Wife

Psychological Factors:

  • Family Mental Health History: No significant family mental health history reported.
  • Previous Mental Health Treatments: Neither client reports any previous mental health treatment.
  • Previous Mental Health Assessments: No prior mental health assessments reported.
  • Symptom 1:
    • Symptom Description: Frequent heated arguments, poor communication, difficulty resolving conflicts.
    • Onset: 1 year ago, since getting married
    • Frequency: Multiple arguments per week
    • Ascendance: Worsening over past 6 months
    • Intensity: Severe, intense arguments lasting 30+ minutes
    • Duration: 1 year
    • Quote (Symptom): "We've been fighting constantly since we got married." - Wife

Biological Factors:

  • Family Medical History: No significant family medical history reported.
  • Medical Conditions: Both clients report good physical health with no chronic medical conditions.
  • Sleep: Wife reports occasional insomnia due to feeling anxious about relationship issues. Husband reports no sleep disturbances.
  • Nutrition: Both clients report healthy diets with no nutritional concerns.
  • Physical Activity: Wife attends yoga classes weekly. Husband goes to the gym 3 times per week. No issues noted with physical activity.
  • Sexual Activity: Wife reports low libido due to relationship conflicts. Husband also acknowledges decline in libido and performance over past 6 months.
  • Substances: Social alcohol use reported by both clients. No problematic substance use noted.

Social Factors:

  • Work Or School: Wife works as a marketing associate. Husband works as an accountant. Both work full time with no reported issues.
  • Relationships: Married 1 year. Overall good relationships with friends and family. Social life has declined recently due to relationship issues.
  • Recreation: Previously enjoyed shared hobbies like hiking but this has declined over past year due to relationship tension. Each also engages individual interests.
  • Family Social History: Wife grew up in intact family, 1 younger brother. Husband grew up in divorced family, 1 older sister. Both report supportive childhoods.
  • Other Relevant Social Factors: No other relevant social factors reported.
  • Traumatic Experiences: No trauma history reported by either partner.
  • Physical Intimacy: Wife reports decline in intimacy and affection due to constant arguing. Husband also acknowledges decrease in sexual activity over past 6 months.
  • Intimacy Satisfaction: Both clients express dissatisfaction with current sexual relationship due to strained overall relationship dynamics and frequent conflicts.
    • Quote (Intimacy Satisfaction): "We barely have sex anymore because we've been fighting so much." - Wife

Clinical Assessment:

  • Clinical Conceptualization: Frequent conflict in the early years of marriage appears exacerbated by poor communication skills, difficulty listening, and lack of healthy conflict resolution strategies. No individual psychopathology evident currently. Both clients appear motivated to improve relationship.
  • Diagnosis 1:
    • Diagnosis Description: Relational Stress Related to Marriage
    • DSM-5 Code: V61.10
    • ICD-10 Code: Z63.0
    • Reasoning: Relationship distress and frequent conflict expressed by both partners beginning after 1 year of marriage.
  • Comorbidity: No comorbid diagnoses at this time.
  • Assessment Tool: Clinical Interview
  • Results: Read above.
  • Status: Additional assessments may be considered after initial sessions to further evaluate relationship dynamics.

Mental Status Exam:

  • Mood And Affect: Wife presented as tearful when discussing relationship conflicts. Husband appeared frustrated at times. Affect was mood-congruent for both.
  • Speech And Language: Speech clear, coherent, and normal rate/tone for both clients.
  • Thought Process And Content: Thought process logical and goal-directed. Thought content focused on relationship.
  • Orientation: Both clients oriented x3.
  • Perceptual Disturbances: No perceptual disturbances noted for either client.
  • Cognition: Cognition grossly intact for both clients based on session interactions.
  • Insight: Limited insight into impact of own behaviors on relationship currently but open to gaining understanding.

Risk Assessment

  • Risks Or Safety Concerns: No risks or safety concerns reported currently. No indications of violence, abuse, or neglect in the relationship by either partner.
  • Hopelessness: Neither client expressed hopelessness or worthlessness during the intake. Both appear motivated to improve relationship.
  • Suicidal Thoughts Or Attempts: No reports or indications of suicidal ideation for either client during intake session.
  • Self Harm: No evidence or reports of self harm behaviors by either client.
  • Dangerous To Others: No indications of homicidal ideation or danger to others based on session.
  • Quote (Risk): “ We fight like hell, but we love each other.”  Husband
  • Safety Plan: No safety plan was indicated or developed during this initial session.

Strengths And Resources:

  • Internal Strengths: Both clients exhibit insight into relationship problems and motivation to improve marriage. Sense of humor and creativity noted.
  • External Resources: Report strong family support from both sides. Close friendships outside of marriage. Employed full-time with financial stability.
  • Quote (Resources): "My parents have a great marriage and are happy to give us advice." - Wife

Interventions

  • Therapeutic Approach Or Modality: Psychoeducation provided on Gottman Method and CBT approaches. Emotion coaching and active listening techniques introduced.
  • Psychological Interventions:
    -Validated feelings and relationship struggles.
    -Guided clients through an active listening exercise.
    -Assigned reading on managing marriage conflict.
  • Rationale: Gottman Method and CBT approaches chosen to help improve emotional awareness, communication and conflict resolution skills.

Progress And Response

  • Response To Treatment: Clients were engaged in the intake session and open to learning new skills. Motivated to improve marital relationship. Rapport established.
  • Specific Examples Or Instances: Each partner actively participated in the active listening exercise and discussion. Completed sample worksheet on identifying emotions.
  • Quote (Progress): "I'm ready to learn how we can argue in a healthier way." - Wife
  • Challenges To Progress: No challenges expressed at this time. Consistency in practicing new skills outside of sessions may be difficult.
  • Therapist Observations And Reflections: Arguments appear driven by poor communication rather than individual pathology. Each partner exhibits negative patterns of interacting. Progress will require insight and motivation from both.
  • Therapeutic Alliance: Strong therapeutic alliance established with both clients through empathy, validation and active listening. No ruptures noted.

Discussed Goals:

  • Goal 1:
    • Goal Description: Improve communication skills including active listening, empathy, and expressing needs.
    • Metrics: Observe improved communication during sessions. Self-report of increased understanding.
    • Attainability: Attainable through consistent skills practice and insight into relationship dynamics.
    • Relevance: Central to presenting complaints regarding poor communication and frequent arguments.
    • Timeframe: Work weekly in session on building skills.
    • Quote (Goal): "I want us to get better at listening and understanding each other." -Wife
  • Goal 2:
    • Goal Description: Learn effective conflict resolution strategies to reduce relationship tension.
    • Metrics: Count and monitor arguments, disagreements week to week. Self-report of increased resolution.
    • Attainability: Attainable through learning de-escalation skills and implementing during real-time conflicts.
    • Relevance: Directly relevant to presenting issue of unresolved conflicts and heated arguments.
    • Timeframe: Work weekly in session with practice exercises for real-world application.
    • Quote (Goal): Husband: "I want to get better at diffusing things before it turns into a big fight."
  • Barriers To Achieving Goals: Lack of insight into own role in relationship patterns currently. Resistance to changing engrained interaction styles.

Follow Up Actions And Plans:

  • Homework: Read psychoeducational handout on managing marital conflict. Practice active listening skills at home.
  • Plan For Future Session: Continue Gottman and CBT interventions. Introduce conflict resolution strategies.
  • Plans For Continued Treatment: Schedule weekly conjoint 50 minute therapy sessions.
  • Coordination Of Care: No need for coordination of care identified currently.