Note Examples
Example Intake

Example Intake

Session Title: Initial Intake Session for 11-Year-Old Client with Severe Anxiety
Brief Summary of Session: This session involved the initial intake for an 11-year-old client referred by their pediatrician due to severe anxiety symptoms. The client exhibited excessive worrying, sleep difficulties, somatic complaints, and avoidance behaviors affecting her social and academic life. Cognitive Behavioral Therapy (CBT) interventions were introduced to help the client identify and reframe anxious thoughts. The client actively engaged in therapy, displaying strong family support. Goals were set to reduce anxiety symptoms and enhance overall functioning, and the client was given homework to track anxious thoughts.

Consent: The therapist reviewed limits of confidentiality, including harm to self or others, abuse and neglect, and court orders. Client rights and responsibilities were reviewed verbally. Client signed informed consent document indicating understanding of policies. Client presented as fully comprehending the informed consent process. Therapist mentioned that the mother signing the consent form.

  • Quote (Consent): "I understand you have to tell my mom or someone if I want to hurt myself or someone else."

Presentation:

  • Chief Complaint: The 11-year-old female client was referred due to excessive worrying, sleep difficulties, stomachaches, and avoidance of social situations and new experiences. These symptoms have persisted for six months and worsened.
    • Quote (Chief Complaint): "I worry all the time about everything. I can't sleep. My stomach hurts. I don't want to go to parties or sleepovers."
  • Impairments and Challenges: Anxiety significantly impairs her social and academic functioning. She avoids social events, experiences concentration difficulties in school, frequent somatic complaints, and a decline in academic performance.
    • Quote (Impairments and Challenges): "I don't want to go anywhere anymore. School is hard because I can't focus. My stomach hurts every morning."

Psychological Factors:

  • Family Mental Health History: Client's mother has a generalized anxiety disorder; maternal grandmother has a history of anxiety and depression.
  • Previous Mental Health Treatments: No prior mental health treatment.
  • Symptom 1:
    • Symptom Description: Excessive worrying and anxiety across various settings and domains.
    • Onset: Started six months ago.
    • Frequency: Daily, throughout much of the day.
    • Ascendance: No improvement reported.
    • Intensity: Severe, very distressing.
    • Duration: Six months
    • Quote (Symptom): "I worry all the time about everything school, friends, family. I can't stop worrying even when I try."
  • Symptom 2:
    • Symptom Description: Difficulty sleeping, including problems falling asleep and staying asleep.
    • Onset: Started six months ago.
    • Frequency: 5-6 nights per week.
    • Ascendance: No improvement reported
    • Intensity: Moderate, significant distress and daytime fatigue.
    • Duration: Six months
    • Quote (Symptom): "It's so hard for me to fall asleep at night because I can't stop worrying. Even when I do sleep, I toss and turn all night."

Biological Factors:

  • Medications: No medications reported.
  • Allergies: No known allergies.
  • Family Medical History: The client's paternal grandfather had heart disease.
  • Medical Conditions: No reported medical conditions.
  • Sleep: Difficulty falling and staying asleep most nights due to excessive worrying, leading to daytime fatigue.
  • Nutrition: Maintains a balanced diet, but appetite is occasionally reduced due to anxiety.
  • Physical Activity: Enjoys playing soccer on weekends but has avoided sports due to anxiety symptoms.

Social Factors

  • Work or School: Thirdgrade student; academic performance has declined due to anxiety.
  • Relationships: Parents divorced two years ago, coparent effectively. The client primarily lives with her mother and older sister, has close relationships with both parents and her sister, but avoids friends and social situations.
  • Recreation: Previously enjoyed soccer, drawing, and playing with friends but now spends free time at home, withdrawn.
  • Family Social History: Parents divorced two years ago after a 10year marriage, and the client splits her time evenly between both parents' homes.
  • Other Relevant Social Factors: The family recently moved to a new neighborhood approximately eight months ago.
  • Traumatic Experiences: No traumatic experiences reported.

Clinical Assessment

  • Clinical Conceptualization: Anxiety symptoms may have biological underpinnings given the family history of anxiety. Psychosocial stressors, including parental divorce and moving to a new school, may have triggered her anxiety. Maladaptive thoughts and behaviors such as avoidance and sleep difficulties exacerbate her condition. Protective factors include family support and previous enjoyment of extracurricular activities.
  • 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 settings and domains nearly every day for the past six months, causing significant distress and impairment.
  • Comorbidity: No comorbid conditions noted at this time.
  • Assessment Tool: Clinical Interview
  • Results: Read above.
  • Status: The initial intake has been completed. Additional assessment tools may be used after 23 sessions to further evaluate symptoms.

Mental Status Exam

  • Mood and Affect: Anxious mood and restricted affect; became tearful when discussing anxiety.
  • Speech and Language: Clear, coherent, ageappropriate speech.
  • Thought Process and Content: Logical, goaldirected thought process focused on worries in various domains.
  • Orientation: Oriented in all three spheres.
  • Perceptual Disturbances: No perceptual disturbances.
  • Cognition: Age appropriate attention and memory; difficulty concentrating due to anxiety.
  • Insight: Limited insight into her anxiety, but willingness to engage in treatment.

Risk Assessment:

  • Risks or Safety Concerns: The client denied suicidal ideation, intent, or a plan. There was no indication of homicidal ideation or psychosis, and no safety concerns were noted at this time.
  • Hopelessness: The client reported feeling sad due to anxiety but denied feelings of hopelessness or worthlessness.
  • Suicidal Thoughts or Attempts: The client denied past and present suicidal ideation, intent, or a plan.
  • Self-Harm: There was no evidence or report of selfharm behaviors.
  • Dangerous to Others: There was no evidence or report of homicidal thoughts or plans.
  • Quote (Risk): "I want to be happy."
  • Safety Plan: No safety concerns were noted at this time.

Strengths and Resources:

  • Internal Strengths: The client is intelligent and creative, enjoying sports and arts.
  • External Resources: The client has a supportive family, with both parents involved in treatment, and she attends school regularly.
  • Quote (Resources): "My family helps me a lot when I'm worried. My parents said they will help me get better."

Interventions:

  • Therapeutic Approach or Modality: Cognitive-behavioral therapy interventions were introduced to help the client identify, evaluate, and modify maladaptive thoughts that exacerbate anxiety.
  • Psychological Interventions:
  • Psychoeducation was provided about the CBT model.
  • Thought records were introduced to track anxious thoughts and identify cognitive distortions.
  • Rationale: CBT interventions are aimed at teaching coping skills to reduce anxiety by changing thought patterns and behaviors that maintain symptoms.

Progress and Response

  • Response to Treatment: This was the initial intake session, and the client displayed motivation to reduce anxiety symptoms and was willing to engage in CBT treatment. Rapport was successfully established.
  • Specific Examples or Instances: The client actively participated in introducing the CBT model and completed a sample thought record with therapist input.
  • Quote (Progress): "I'm ready to try and stop worrying so much. I want to get better."
  • Challenges to Progress: No challenges were reported at this time. The client may face difficulties with consistent practice of CBT skills outside of therapy.
  • Therapist Observations and Reflections: The therapist observed an anxious mood and cognitive distortions related to overestimating danger during the session. The client became tearful when discussing her anxiety but displayed willingness to engage in treatment. The family is expected to be a good source of support.
  • Therapeutic Alliance: No obstacles to therapeutic alliance noted at this time. Client presented as open and willing to engage in treatment. Therapist utilized empathy, active listening and validation skills to establish rapport. A strong therapeutic relationship will be essential for implementing CBT interventions effectively moving forward.

Discussed Goals:

  • Goal 1:
    • Goal Description: Reduce anxiety symptoms to a manageable level that no longer interferes with social and academic functioning.
    • Metrics: Monitor anxiety symptoms weekly using subjective units of distress scale and evidencebased rating scales like SCARED.
    • Attainability: This goal is attainable with consistent application of CBT skills and family support.
    • Relevance: Directly relevant to the client's presenting problems and impacts her quality of life.
    • Timeframe: Work towards gradual symptom reduction over the next 6-8 weeks.
    • Quote (Goal): "I want to worry less so I can go to parties again and sleep at night."
  • Goal 2:
    • Goal Description: Return to full school attendance and participation.
    • Metrics: Monitor school attendance, class participation, and completion of assignments.
    • Attainability: This goal is attainable once anxiety is better managed.
    • Relevance: Necessary for academic and social development.
    • Timeframe: Work towards this goal over the next 46 weeks.
    • Quote (Goal): "I don't want to keep missing school because I'm worried or don't feel good."
  • Barriers to Achieving Goals: Limited insight into anxiety at present. The client may struggle with consistent practice of CBT skills outside of therapy.

Follow Up Actions and Plans

  • Homework: The client is tasked with practicing the identification of automatic negative thoughts and cognitive distortions using thought records. She is to complete three thought records during the current week.
  • Plan for Future Session: The plan for the next session involves continuing CBT psychoeducation and skills training. Behavioral activation will also be introduced to reduce avoidance behaviors.
  • Plans for Continued Treatment: Weekly 50minute sessions will be scheduled for the next 68 weeks to further assess and treat anxiety symptoms.
  • Coordination of Care: The parent has signed a release to coordinate care with the pediatrician who made the referral and may prescribe medication if needed. Psychoeducation has been provided to the parent on how to support the use of CBT skills at home.