Initial Psychotherapy Assessment for EX: Template

Intake Report for Psychotherapy:
Referral Reason:
- The client, a 35-year-old female, is experiencing heightened anxiety and stress due to recent changes in her work environment and personal life. She seeks counseling to manage these emotions and enhance her coping mechanisms.
Family makeup:
- The client is married with two children, ages 8 and 10. Her husband is supportive, and they maintain a stable home environment. She is employed as a marketing manager.
- Family history includes a maternal history of anxiety disorders.
Background Information:
- The client reports a history of anxiety since her teenage years, with occasional panic attacks. She has not undergone any surgeries.
- Currently taking sertraline 50mg daily for anxiety.
- No known allergies.
Psychosocial History:
- The client has a robust social network, including close friends and family.
- She holds a bachelor's degree in marketing and has been employed in her current role for five years.
- The client has been in a stable marriage for 12 years.
Life history/family history: The client grew up in a supportive family environment, with both parents present. She has one sibling. No significant hospitalizations. Financially stable.
Expectations/goals for treatment:
- The client aims to reduce anxiety levels, improve stress management skills, and enhance overall well-being.
Impressions: The client presents as motivated and engaged in the therapeutic process. She exhibits moderate stress levels but demonstrates a strong commitment to treatment.
Mental Status Examination:
- Appearance: Neatly dressed, well-groomed.
- Behavior: Cooperative and attentive.
- Mood: Anxious but hopeful.
- Affect: Congruent with mood.
- Thought Process: Logical and coherent.
- Thought Content: Focused on current stressors.
- Cognition: Intact.
- Insight: Good understanding of her condition.
- Judgment: Sound decision-making skills.
Assessment:
- Generalized Anxiety Disorder (GAD) with situational stressors.
Plan:
- Continue sertraline 50mg daily.
- Begin cognitive-behavioral therapy (CBT) to address anxiety and develop coping strategies.
- Schedule weekly therapy sessions for ongoing support and progress monitoring.