Note Examples
Example Intake

Example Intake

  • Session Title: Family Therapy Intake: Presenting Issues of Communication, Conflict, and Parent-Child Relationships.
  • Brief Summary Of Session: The family attended their first family therapy session to address issues with communication, frequent conflicts, and parent-child relationships. The parents described frustration communicating with their teenage daughter. The daughter shared feeling unsupported. The therapist helped each family member express their concerns and expectations for therapy.
  • *Consent:**The therapist reviewed confidentiality, its limits, payment policies, and the client rights and responsibilities form with the family. All 3 members verbally agreed to counseling.
    • Quote (Consent): "Yes, we understand and agree to everything that was explained about confidentiality and payment." - Mother

Presentation:

  • Chief Complaint: The chief complaints were poor family communication, frequent conflicts, and strained parental relationships reported by all 3 family members.
    • Quote (Chief Complaint):”We fight all the time lately over little things. We're hoping counseling can help us communicate better as a family." - Father
  • Impairments And Challenges: The family described loud arguments disrupting their home life, impacting relationships and emotional wellbeing. The daughter feels unsupported and withdraws, worsening communication.
    • Quote (Impairments And Challenges): ”The fighting has made our home life very stressful. I don't feel comfortable talking openly anymore." - Daughter
  • Communication Patterns: The parents noted frequent misunderstandings when communicating with their daughter. The daughter feels unheard and uncared for during discussions.
    • Quote (Communication Patterns): ”When I try to talk to her, it seems like she shuts down. I'm not sure she really listens anymore." - Mother
  • Conflict Resolution: The family struggles to resolve conflicts calmly, resorting to yelling or avoidance. Negotiation skills are lacking.
    • Quote(Conflict Resolution): "Our arguments just escalate until someone storms off. We want to learn to resolve things peacefully." - Father
  • Family Dynamics: The parents appear aligned yet disconnected from their daughter. The daughter isolates herself when upset.
    • Quote (Family Dynamics): ”We're supposed to be a team but lately it feels more like it's us versus her." - Father
  • Family Roles: The parents are authority figures who make rules. The daughter rebels against their control.
    • Quote (Family Roles) :”I’m so tired of them treating me like a little kid and bossing me around all the time." - Daughter
  • Family Rules And Boundaries: The parents impose rigid rules that strain their relationship with their teenage daughter seeking independence.
    • Quote (Family Rules And Boundaries): ”She gets so upset whenever we try to set reasonable rules. But we're just trying to keep her safe." - Mother

Psychological Factors:

  • Family Mental Health History: No significant family mental health history reported.
  • Previous Mental Health Treatments: The daughter saw a school counselor earlier this year for anxiety. No other treatment reported.
  • Previous Mental Health Assessments: No previous mental health assessments reported.

Biological Factors:

  • Family Medical History: Father has high blood pressure. Otherwise, no major medical conditions reported.

Social Factors:

  • Family Social History: The family identifies as upper middle class. The parents have been married 18 years. The daughter is their only child. Both parents work full-time.

Clinical Assessment:

  • Clinical Conceptualization: Family communication issues and parent-child relationship problems likely exacerbated by adolescent developmental stage. Lack of conflict resolution and emotional regulation skills noted.
  • Assessment Tool: Clinical Interview
  • Results: Read Above
  • Status: Intake assessment in progress.

Risk Assessment:

  • Risks Or Safety Concerns: No safety concerns noted during intake.
  • Hopelessness: No expressions of hopelessness noted.
  • Suicidal Thoughts Or Attempts: No suicidal thoughts reported.
  • Self-Harm: No self-harm reported.
  • Dangerous To Others: No danger to others reported.
  • Quote (Risk): “We are here to help each other.”
  • Safety Plan: None mentioned.

Strengths And Resources:

  • Internal Strengths: Family exhibits cooperation in attending first session together. Individual members show self-awareness of problems.
  • External Resources: Parents have social support through jobs and family nearby. Daughter has friends at school.
  • Quote (Resources): "I'm glad we're finally getting help. I know we all want our family to be close again." - Daughter

Interventions:

  • Therapeutic Approach Or Modality: Cognitive-behavioral therapy, communication skill building, parenting education
  • Psychological Interventions:
    • Validated each family member's concerns and feelings.
    • Encouraged open communication.
    • Assigned homework to identify individual goals.
  • Rationale: Interventions aimed to build therapeutic alliance, assess expectations, and elicit each individual's hopes for change.

Progress And Response:

  • Response To Treatment: Family members appeared open and engaged during first session
  • Specific Examples Or Instances: Each member contributed to discussions and completed check-in assessment.
  • Quote (Progress): "I appreciate you taking the time to hear from all of us today." - Mother
  • Challenges To Progress: Daughter appeared reserved when parents were speaking. May take time to build trust.
  • Therapist Observations And Reflections: Family exhibits both strengths and areas for improvement that can be leveraged in treatment. The daughter may need individual attention to process her feelings.
  • Therapeutic Alliance: Alliance is developing but will need to be nurtured, particularly with the daughter.

Discussed Goals:

  • Goal 1:
    • Goal Description: Improve family communication and listening skills.
    • Metrics: Count and monitor family arguments. Track use of active listening.
    • Attainability: Attainable with communication skill building and individual practice.
    • Relevance: Highly relevant to presenting complaint of poor communication.
    • Timeframe: Work on skills in session and at home. Assess progress weekly.
    • Quote (Goal): "I want us to really hear each other and stop talking over people." - Mother
  • Barriers To Achieving Goals: Lack of insight into different family members' perspectives. High emotional reactivity during conflicts.

Follow Up Actions And Plans:

  • Homework: Each member will complete a worksheet identifying individual therapy goals to discuss next session.
  • Plan For Future Session: Next session will focus on establishing treatment goals based on issues identified during intake. Communication skill building will begin.
  • Plans For Continued Treatment: Weekly 50-minute family therapy sessions agreed upon for the next 8 weeks to start.
  • Coordination Of Care: Parents will sign release of information form to coordinate care with daughter's school counselor.