Therapy Intake Generator

Comprehensive Therapy Intake Note

1. Identifying Information and Reason for Visit

• Client Name: Garrett

• Age: 20

• Gender: Male

• Ethnicity: White

• Living Situation: Resides with parents and younger brother

• Reason for Visit: Garrett presents to therapy due to significant anxiety related to the transition from high school to adult life, exacerbated by a history of anxiety and autism. He expresses feelings of stress regarding new responsibilities and decision-making, impacting his overall functioning.

2. Presenting Problems

• Onset: Garrett reports experiencing anxiety throughout his life, with the severity increasing significantly during the recent transition from high school to adulthood.

• Duration: History of chronic anxiety, with recent exacerbation noted over the past year.

• Triggers: Major life changes, including graduation and the anticipation of adult responsibilities.

• Severity: Anxiety reported as significantly impairing; Garrett describes it as overwhelming at times, particularly when considering future career choices and social interactions.

• Functional Impact: Difficulty in socializing outside his home life, reliance on family support for emotional stability, and impacting work performance at the aquatic center.

3. Psychosocial History

• Family/Supports: Garrett has a supportive family, including engagement with parents and peers. He has reported past difficulties in his relationship with his father, which has improved over time. His younger brother has ADHD and anxiety.

• Education/Work: Currently employed at an aquatic center, responsible for admissions and concessions. Plans to take an orientation class at Midstate Tech to ease the transition to college.

• Living Situation: Lives with parents and younger brother, indicating a secure and stable home environment.

• Cultural Factors: No religious affiliation; does not attend church and has expressed indifference towards religious practices.

4. Relevant Medical and Psychiatric History

• Current Medications:

  • Vyvanse 30mg, 1X daily

  • Escitalopram 20mg, 1X daily

  • Guanfacine 3mg, 1X daily

• Prior Diagnoses:

  • Generalized Anxiety Disorder (F41.1)

  • Provisional Social Anxiety Disorder (F40.10)

  • Unspecified Attention-Deficit/Hyperactivity Disorder (F90.9)

  • Autism Spectrum Disorder (F84.0)

• Treatment Response: Garrett reported that medication was initially helpful but has seen an increase in anxiety with life changes.

• Therapeutic History: Previously engaged in therapy for suicidal thoughts and feelings of helplessness but has not experienced suicidal ideation since 2020.

5. Substance Use

• No substance use reported; no legal issues noted.

6. Risk Assessment and Safety Plan

• Suicidal Ideation (SI)/Homicidal Ideation (HI): No current SI reported. Last occurrence was in 2020.

• Self-harm: No self-harm behaviors reported.

• Protective Factors: Strong family support, positive engagement with friends, and an interest in peer mentorship.

• Safety Plan: Continue to maintain open communication with family and friends and utilize coping strategies discussed in therapy.

7. Clinical Impressions and Provisional Diagnosis

• Garrett displays symptoms consistent with Generalized Anxiety Disorder and Social Anxiety Disorder, as evidenced by his chronic anxiety, exacerbated stressors, and avoidance of social interactions outside his familial support. Provisional diagnoses under consideration include:

  • F41.1 Generalized Anxiety Disorder

  • F40.10 Provisional Social Anxiety Disorder

  • F90.9 Unspecified Attention-Deficit/Hyperactivity Disorder

  • F84.0 Autism Spectrum Disorder

8. Client Goals and Initial Treatment Plan

• Goals:

  • To reduce anxiety levels during life transitions and develop coping mechanisms.

  • To become more comfortable with adult responsibilities and social interactions outside of his home life.

  • To explore potential career paths and gain clarity on future aspirations.

• Initial Treatment Plan:

  • Frequency: Weekly sessions for 6-8 weeks to establish a therapeutic relationship and assess progress.

  • Modalities: Cognitive Behavioral Therapy (CBT) focusing on anxiety management, social skills training, and supportive counseling.

  • Homework/Next Steps: Engage in gradual exposure activities to social situations outside of the home and maintain a journal to track anxiety triggers and responses.

Signature:
[Clinician Name]
[Licensure Information]
[Date]

Therapy Intake Note

1. Identifying Information and Reason for Visit:

• Client Name: William

• Age: 37

• Gender: Male

• Cultural Identity: Native American

• Date of Intake: [Insert Date]

• Setting: Wood County Jail Recovery Pod

• Referral Source: Self-referred as a participant in the Wood County Jail Recovery Pod Program to avoid the revocation of probation through the Wisconsin Department of Corrections.

Reason for Visit: William presents with concerns related to past substance abuse, mental health symptoms, and difficulties adjusting to jail dynamics, particularly feelings of being bullied in the cell block.

2. Presenting Problems:

• Onset and Duration: Issues with substance abuse began in childhood; incarceration has been a recurring theme since age 16. Current incarceration has lasted for approximately one month.

• Triggers: Interpersonal conflicts and feelings of bullying within the jail environment contribute to his distress.

• Severity: Reports significant distress from perceived bullying, fear of aggression leading to expulsion from the recovery pod, and the ongoing battle with substance use.

• Functional Impact: Struggling to maintain composure in a challenging environment; previous attempts to achieve sobriety have been unsuccessful.

3. Psychosocial History:

• Family/Supports: William has a complex family history, having been raised by a mother with substance use issues and having experienced abuse by his aunt and uncle. He has a significant other, Kristi, whom he considers his wife; their relationship is a source of motivation.

• Education/Work: Completed high school while incarcerated; has experience running a screen printing business. Has taken various vocational classes in prison.

• Living Situation: Currently residing in the recovery pod at the jail; has faced instability due to incarceration.

• Cultural Factors: Identifies strongly with Native American culture; expresses that it is an important aspect of his life and recovery journey.

4. Relevant Medical and Psychiatric History:

• Previous Diagnoses: Previously diagnosed with "bipolar schizophrenia"; current understanding aligns with schizoaffective disorder, bipolar type.

• Prior Treatments: Hospitalized involuntarily three times as a juvenile; prescribed medications including Geodon, Lithium, Risperidone, and Risperdal with varied effectiveness.

• Current Medications: Currently on Suboxone (16mg daily) for opioid use disorder; previously on Vyvanse.

5. Substance Use:

• History: Initiated substance use at age 9 with exposure to meth and heroin; self-reports long-standing addiction issues, particularly with heroin.

• Current Status: In recovery pod as part of a mandated program; demonstrates insight into the need for sobriety.

6. Risk Assessment and Safety Plan:

• Self-Injury/Suicidal Ideation: William denies any current or past suicidal ideation or self-harm behaviors.

• Access to Means: Incarceration limits access to means for harm; currently supervised in a controlled environment.

• Protective Factors: Willingness to seek help; desire for a stable relationship with Kristi and to lead a sober life.

7. Clinical Impressions and Provisional Diagnosis:

• Clinical Impressions: William presents with a complex interplay of mental health symptoms, substance use disorder, and external stressors related to his current environment.

• Provisional Diagnosis: Schizoaffective Disorder, Bipolar Type; Opioid Use Disorder.

8. Client Goals and Initial Treatment Plan:

• Client Goals:

  • To maintain composure and avoid aggressive responses to bullying.

  • To achieve sobriety and work towards a happier life, particularly for the sake of his relationship with Kristi.

• Initial Treatment Plan:

  • Frequency: Weekly sessions during incarceration.

  • Modalities: Cognitive-behavioral therapy to address coping skills, psychoeducation about schizoaffective disorder, and substance use recovery strategies.

  • Homework/Next Steps: Explore triggers related to feelings of bullying; develop personalized coping strategies. William will identify positive reaffirmations he can use when facing conflicts.

Next Appointment: [Insert Date and Time]

Therapist Signature: [Your Name, Credentials]
Date: [Insert Date]

Therapy Intake Note

1. Identifying Information and Reason for Visit

• Client Name: Morgan [Last Name]

• Date of Birth: [MM/DD/YYYY] (17 years old)

• Date of Intake: [MM/DD/YYYY]

• Gender: Male

• Ethnicity: White

• Living Situation: Resides on a hobby farm in Milladore with father Chris (54), mother Kathy (49), sister Golda (12), and brother Gus (20).

• Reason for Visit: Morgan presents with concerns regarding family dynamics, feelings of anxiety related to social interactions, and a fear of being kicked out of the house when he turns 18.

2. Presenting Problems

• Onset and Duration: Morgan's concerns have been ongoing, influenced by family dynamics and prior bullying experiences.

• Triggers: Incidents of family entering his space without permission, perceived lack of privacy, and recollections of negative peer interactions at school.

• Severity: Morgan expresses significant anxiety and feelings of isolation, describing himself as an introvert who struggles to engage socially.

• Functional Impact: The described concerns contribute to Morgan’s withdrawal from social situations, difficulty in educational settings, and feelings of worthlessness, particularly exacerbated by past bullying experiences which led to suicidal ideation.

3. Psychosocial History

• Family/Supports:

  • Morgan reports a close relationship with his aunt Heather and uncle Steve.

  • His relationship with sister Golda is described as improving but still “not the best.”

  • He maintains a good relationship with his father, who engages in activities like playing Warhammer to strengthen their bond.

  • Morgan feels that his relationship with his mother is “iffy.”

• Education/Work:

  • Currently enrolled in online schooling through STRIDE but was previously unsuccessful.

  • Morgan will attend Assumption High School starting Fall 2025.

  • He has previously attended Auburndale High School but left due to bullying which significantly impacted his academic performance.

  • Currently unemployed after quitting a job as a detailer at TJ’s Auto.

• Living Situation: Morgan has his own room on the family farm but expresses feeling isolated.

• Cultural Factors: Morgan reports no spiritual beliefs.

4. Relevant Medical and Psychiatric History

• Medical Conditions: Morgan is underweight for his age with no other medical concerns reported.

• Current Medications:

  • Duloxetine 30 mg (antidepressant)

  • Aripiprazole 2 mg (antipsychotic)

• Prior Diagnoses/Treatment Response: Specific diagnoses were not disclosed; however, Morgan has a history of bullying leading to suicidal thoughts. He is currently receiving medication as part of a treatment plan.

5. Substance Use

• Morgan reports no issues with substance use at the time of intake.

6. Risk Assessment and Safety Plan

• Self-harm/Suicidal Ideation: Morgan has a history of suicidal ideation related to bullying experiences. No current suicidal thoughts reported during intake.

• Protective Factors:

  • Supportive relationships with his father, aunt, and uncle.

  • Interest in engaging in activities such as Warhammer with his father.

  • Desire to improve social skills and become more outgoing.

• Safety Plan: Collaboration with Morgan to create a plan involving safe coping strategies, identifying warning signs, and emergency contacts if feelings of distress arise.

7. Clinical Impressions

• Morgan presents with symptoms consistent with anxiety and possible depression stemming from social isolation and trauma related to past experiences with bullying. His concerns around family dynamics and fear of abandonment further complicate his mental health state. A provisional diagnosis may include Generalized Anxiety Disorder (GAD) and Adjustment Disorder (with anxiety).

8. Client Goals and Initial Treatment Plan

• Goals:

  • Develop social skills and decrease anxiety in social situations.

  • Improve familial communication and boundaries.

  • Enhance coping strategies to manage anxiety and fear of abandonment.

• Initial Treatment Plan:

  • Frequency of sessions: Weekly individual therapy.

  • Modalities: Cognitive Behavioral Therapy (CBT) to address negative thought patterns, and Social Skills Training to bolster interactions.

  • Homework/Next Steps:

    • Morgan will maintain a daily log of social interactions and feelings associated with them.

    • Develop a list of personal boundaries he wishes to communicate with family members.

    • Explore interests in IT and identify actionable steps toward pursuing this career path.

Signature:
[Your Name, Credentials]
[Your Title]
[Date]

Therapy Intake Note

1. Identifying Information and Reason for Visit:

• Client Name: Charlotte Jane Willis

• Date of Birth: 4/23/1966

• Age: 59

• Gender: Female

• Ethnicity: Black

• Date of Assessment: [Insert Date of Assessment]

• Referring Individual: Pamela Harris (Sister)

• Reason for Visit: Client presented for a crisis assessment due to self-reported suicidal ideation, feelings of worthlessness, and persistent substance use. Client expressed a desire for help and indicated being in denial regarding her mental health and substance use issues.

2. Presenting Problems:

• Onset: Concerns began escalating approximately 12-13 years ago with increased alcohol use and feelings of worthlessness.

• Duration: Client reports daily depressive symptoms and recurrent thoughts of self-harm over the last several months.

• Triggers: Recent job loss, multiple bereavements (including two brothers), and perceived harassment at previous employment.

• Severity: Client reported moderate suicide risk due to excessive alcohol consumption and significant emotional distress.

• Functional Impact: Limited ability to engage in daily activities, reported sleeping only 3-4 hours per night, and a diminished interest in previously enjoyed activities. Client is currently living with her sister but is reportedly at risk of homelessness if she does not seek treatment.

3. Psychosocial History:

• Family/Supports: Client lives with her sister Pamela Harris, and another sister, Felita. Reported feelings of being a burden to her family. Strong support system identified, including her children.

• Education/Work: Client has lost her job in Georgia due to performance issues and harassment, has been in Ohio for one month. Previous social drinker status reported, with recent change to daily drinking.

• Living Situation: Currently residing with sister; however, expressed concerns regarding acceptance in the household if she does not comply with treatment recommendations.

• Cultural Factors: Client has articulated a strong faith in God, although feels her prayers are unanswered, which contributes to feelings of hopelessness.

4. Relevant Medical and Psychiatric History:

• Medications: Client reports using Benadryl for insomnia, no current prescribed medications known.

• Prior Diagnoses: Client has a self-reported history of bipolar disorder but cannot specify further details.

• Treatment Response: Client has a history of hospitalization due to a suicide attempt. Previous mental health treatment history is unclear.

5. Substance Use:

• Client reports alcohol use beginning approximately 10 years ago, escalating to daily use over the last few years. Describes drinking "every day, all day," with Budweiser as her drink of choice.

• Client reports being unable to recall specifics regarding frequency and quantity of use, indicating possible disorganization and denial.

6. Risk Assessment and Safety Plan:

• Suicidal Ideation: Client endorses recurrent thoughts of self-harm but denies a specific plan or intent at this time.

• Protective Factors: Client has children and responsive siblings as potential protective factors. Expressed interest in inpatient treatment as a means of safety and recovery.

• Access to Means: Client has no access to lethal means such as firearms.

• Current Risk: Moderate risk due to recent alcohol consumption and expressed feelings of worthlessness. Recommended immediate transport to inpatient facility for further assessment and safety stabilization.

7. Clinical Impressions and Provisional Diagnosis:

• Client exhibits signs consistent with Major Depressive Disorder, including anhedonia, insomnia, feelings of worthlessness, and suicidal ideation. Possible co-occurring Substance Use Disorder related to alcohol use is indicated.

• Provisional Diagnosis: Major Depressive Disorder (MDD) and Alcohol Use Disorder (AUD), pending further evaluation.

8. Client Goals and Initial Treatment Plan:

• Client expressed a desire to enter an inpatient facility to undergo detox and receive a comprehensive mental health evaluation.

• Initial Plan:

  • Transport client to Highland Springs for an immediate assessment.

  • Facilitate connection with case management for ongoing support during inpatient stay.

  • Recommend follow-up appointments post-discharge for continued mental health and substance abuse treatment.

  • Discuss potential outpatient therapy options to address long-term recovery and coping strategies.

  • Frequency of sessions to be determined based on client’s needs following assessment results.

  • Encourage client to journal or reflect on feelings and experiences during treatment for self-awareness and integration in therapy.

Signature:
[Your Name], LCSW
[Your Title / Credentials]
[Date]