2026 Intake assessment examples for therapists

[Patient name], a 34-year-old self-referred via primary care, presents with 'I can't stop worrying — it's interfering with my work.' Onset roughly 8 months ago following a job change. Symptoms include daily excessive worry across multiple domains (work performance, finances, partner's safety), restlessness, difficulty concentrating, sleep onset latency of 90+ minutes, and three discrete panic-like episodes in the past month. No previous therapy. Patient identifies 'thinking about thinking' as the most distressing feature.

No prior psychiatric treatment. No psychotropic medications. Medical: hypothyroidism, well-controlled on levothyroxine; otherwise unremarkable. Family psychiatric: mother treated for depression in her 40s; maternal aunt with anxiety. Social: married 6 years, no children, stable employment in tech. Developmental: unremarkable. Substance use: 4-6 drinks/week, denies recreational use. Trauma: denies major trauma; reports a 'stressful childhood' with a critical father, declines to elaborate at this time.

Appearance: appropriately groomed, well-dressed. Behavior: cooperative; mildly fidgety. Mood: 'tense'. Affect: anxious, full range, congruent. Speech: rate increased, normal volume and prosody. Thought process: linear, occasionally circumstantial when discussing work. Thought content: pervasive worry; denies SI/HI, delusions, hallucinations. Cognition: oriented x4; concentration mildly impaired by intrusive worry. Insight: good. Judgment: intact.

Denies current SI, HI, plan, intent, means. No history of attempts or self-harm. Protective factors: marriage, stable employment, no substance dependence, intact insight, strong help-seeking behavior (self-referred). Risk: low.

Generalized Anxiety Disorder (F41.1), moderate severity. Rule out: Panic Disorder (F41.0) — three panic-like episodes warrant ongoing monitoring; if discrete panic attacks crystallize, code would be revised. PHQ-9: 6 (mild). GAD-7: 16 (severe range). No depressive disorder meets criteria currently.

Weekly individual CBT, 50-minute sessions. Initial goals: (1) reduce GAD-7 to ≤10 within 12 weeks; (2) establish daily thought record practice; (3) reduce sleep onset latency to under 30 minutes. Initial interventions: psychoeducation on the worry-anxiety cycle, introduction of the 3-column thought record, sleep hygiene review. Coordinate with prescriber [Provider] re: SSRI consideration if symptoms persist after 6 sessions. Next session [Date].

[Patient name], a 27-year-old referred by their psychiatrist [Provider], presents with 'I can't control my emotions — I do things I regret.' Patient describes long-standing emotional reactivity, two self-harm episodes in the past year (cutting; non-suicidal), a pattern of intense and unstable relationships, and chronic feelings of emptiness. Reports two prior brief courses of psychotherapy (CBT and supportive) that 'didn't stick.' Patient specifically requests DBT after researching it online.

Psychiatric: two prior outpatient courses as above; one psychiatric ER visit 18 months ago for SI without attempt. Medications: sertraline 100mg daily (prescribed by [Provider]). Medical: unremarkable. Family psychiatric: father with alcohol use disorder; sister with eating disorder. Social: works in healthcare; lives alone; closest support is a sister. Trauma: emotional neglect in childhood; one acquaintance-rape in college. Substance use: occasional cannabis, denies heavy alcohol use.

Appearance: appropriately groomed. Behavior: cooperative; brief moment of dissociation when discussing the assault history. Mood: 'overwhelmed.' Affect: labile, full range, mostly congruent. Speech: rate normal. Thought process: linear. Thought content: passive SI 'sometimes' without current plan or intent; chronic feelings of emptiness. Cognition: intact. Insight: good. Judgment: intact in session; impaired during emotional dysregulation episodes per patient self-report.

Passive SI without current plan, intent, or means. Two NSSI episodes in past 12 months. Prior psychiatric ER visit. Protective factors: insight, help-seeking behavior, sister as support, current psychiatric medication, no substance dependence. Risk: moderate. Safety plan completed in session; 988 number, crisis text line, sister's contact saved.

Borderline Personality Disorder (F60.3), meets 6 of 9 DSM-5-TR criteria. Persistent Depressive Disorder (F34.1) — chronic mild-to-moderate depressive features for over 2 years per patient report. Post-Traumatic Stress Disorder, partial (F43.10) — single discrete trauma with re-experiencing and avoidance, does not meet full criteria currently.

Standard outpatient DBT: weekly individual + weekly skills group (referral pending). Initial individual goals: (1) eliminate NSSI within 6 months; (2) complete the four DBT skill modules within 12 months; (3) reduce SI to absent. Diary card introduced and completed in session. Coach calls available 24/7 for skills coaching only. Coordinate with prescriber [Provider] re: ongoing sertraline. Next session [Date].

[Patient name], a 41-year-old self-referred 5 months after a motor vehicle accident at [Location], presents with 'I can't get past the accident — it's playing in my head.' Symptoms: daily intrusive images of the impact, nightmares 4x/week, hypervigilance while driving, complete avoidance of the intersection where the accident occurred, irritability, sleep disturbance. Patient functioned well prior to the accident. No prior psychiatric history.

Psychiatric: none. Medications: none psychotropic. Medical: minor whiplash from the MVA, otherwise unremarkable. Family: parents living, healthy. Social: long-term partnership, two children, stable employment. Substance use: light social drinking, denies use during/since accident. Trauma: the MVA is the index event; denies prior trauma.

Appearance: appropriately groomed. Behavior: cooperative, slightly startled by an external sound during session. Mood: 'unsettled.' Affect: anxious, mildly constricted. Speech: rate normal. Thought process: linear. Thought content: trauma-focused; denies SI/HI. Cognition: intact. Insight: excellent. Judgment: intact.

Denies SI, HI, plan, intent, means. No history of self-harm. Protective factors: stable family, employment, no substance use, excellent insight. Risk: low.

Post-Traumatic Stress Disorder, acute (F43.11). Full criteria met: re-experiencing (intrusions, nightmares), avoidance (intersection), negative cognitions ('I'm not safe'), and arousal (hypervigilance, sleep disturbance, irritability). PCL-5 administered: 48 (provisional PTSD threshold ≥31).

Weekly EMDR therapy. Initial phases 1-2: history, treatment planning, resourcing (safe place, container, calm-place body cue) over the first 2-3 sessions. Phase 3 assessment of the MVA target memory anticipated by session 4. Reprocessing (phases 4-7) expected to span 8-15 sessions for this single-incident presentation. Coordinate with PCP for any sleep medication consideration if nightmares persist. Next session [Date].

[Patient name], a 38-year-old referred by a colleague, presents with 'I feel split into pieces — like different versions of me are running the show.' Patient describes a long history of feeling 'fragmented,' particularly under stress; chronic difficulty in close relationships; a harsh inner critic; and episodes of emotional flooding followed by numb shutdown. Patient has prior therapy experience (5 years of psychodynamic work) that they describe as 'helpful but slow.' Self-identified interest in IFS.

Psychiatric: prior long-term psychotherapy as described. No medications. Medical: unremarkable. Family: complicated; mother emotionally volatile, father absent during childhood. Social: single by choice currently; close friends; works as a writer. Trauma: chronic developmental relational trauma — emotional unpredictability from primary caregiver; no single discrete traumatic event but persistent attachment disruption. Substance use: occasional wine, no concerning pattern.

Appearance: thoughtfully presented, attuned to internal experience. Behavior: cooperative, introspective. Mood: 'curious but tired.' Affect: full range, congruent. Speech: rate normal, articulate. Thought process: linear, with capacity to observe and describe internal experience in third person ('there's a part of me that...'). Thought content: no SI/HI; rich inner experience. Cognition: intact. Insight: excellent. Judgment: intact.

Denies SI, HI, plan, intent, means. No self-harm history. Protective factors: insight, prior therapy experience, social support, no substance issues, stable work. Risk: low.

Post-Traumatic Stress Disorder, chronic, complex presentation (F43.12) — chronic developmental trauma rather than single-event PTSD. Persistent Depressive Disorder (F34.1) — features of chronic low mood with periods of higher functioning. The IFS framework will guide intervention; ICD-10 diagnosis reflects symptom presentation rather than the conceptual model.

Weekly IFS therapy. Initial sessions: parts mapping and identification of the most active managers and exiles. Goals: (1) develop reliable Self-energy access; (2) build relationships with key protective parts; (3) identify and eventually unburden core exiles in a paced, consensual way. Estimated trajectory: 12-24 months. Next session [Date].