Therapist Notes – Intake Example
Chief Complaint
The client reports experiencing a significant decrease in energy, particularly in the mornings,
which impacts the ability to initiate tasks and start the workday. The client describes a
pervasive feeling of life being "gray," with a notable decline in interest and pleasure in
activities that were once enjoyable, leading to social withdrawal and feelings of hopelessness.
History
Current Medications: None reported.
Developmental: Client grew up as an only child in a middle-class family, often spending time
alone or in after-school programs. Education was described as normal, with no significant
events or traumas.
Family psychiatric: Mother has a history of depression maternal grandfather may have had
untreated anxiety.
Medical: No ongoing medical conditions or treatments occasional headaches possibly related
to stress.
Medication Trials: No history of psychiatric medication trials reported.
Social: Relocated for work three years ago social connections primarily consist of colleagues
family lives several states away. Recent social withdrawal due to lack of energy and interest.
Substance Use: Not specified.
Trauma: No significant trauma reported.
Mental Status Exam
Appearance: Not directly observed
Attention: Client was attentive and engaged throughout the session.
Behavior: Cooperative and forthcoming with personal history and current challenges.
Memory: No memory deficits were apparent during the discussion of personal history.
Mood: Client self-reported persistent low mood.
Affect: Client's affect was congruent with reported mood, indicating feelings of sadness and
hopelessness.
Judgment: Client demonstrated good judgment
Speech: Speech was coherent and goal-directed throughout the session.
Thought content: No evidence of suicidal ideation, homicidal ideation, or psychosis.
Thought process: Thought process appeared logical and organized based on the client's ability
to articulate experiences and symptoms clearly.
Orientation: Client appeared oriented to time, place, person, and situation.
Risk Assessment
Suicidal Ideation: Client denied any thoughts of self-harm or suicidal ideation during the
session.
Homicidal Ideation: No homicidal ideation reported or indicated.
Violent/destructive behaviors: None reported or indicated during the session.
Current Overall Risk: Low risk based on current presentation and self-reporting during the
session. Continuous monitoring is recommended due to depressive symptoms' severity.
Protective Factors: Client has a remote but supportive family network demonstrates insight
into condition by seeking therapy has stable employment despite current struggles with work
performance due to symptoms.
Static risk factors: Family history of depression and possibly anxiety could suggest a genetic
predisposition to mood disorders.
Modifiable risk factors: Current depressive symptoms including low mood, anhedonia, sleep
disturbances, appetite changes, social withdrawal.
Assessment
The client presents with symptoms that are suggestive of a major depressive disorder. Client
experiences pervasive low mood, loss of interest in previously enjoyable activities such as
graphic design and visiting favorite cafés, social withdrawal such as choosing to avoid calls
and interactions due to depleted energy levels, is consistent with patterns of behavior
observed in depressive episodes. Client also express sleep disturbances and contribute to the
client's reported feelings of exhaustion despite long hours spent sleeping. The client's self-
reported lack of energy, particularly in the morning, and difficulty initiating tasks are
indicative of significant impairment in occupational functioning. This is further evidenced by
the client's description of their work environment as a "high-pressure marketing firm" where
they once thrived but now feel overwhelmed and unable to keep up with demands.
Plan
1. Implement CBT techniques targeting identified negative thought patterns and behaviors
that contribute to depressive symptoms.
2. Schedule weekly therapy sessions for continuous monitoring and evaluation of
symptomatology and treatment response.
3. Assign homework involving journaling specific thoughts that exacerbate depressive
symptoms for further examination in therapy.
4. Review progress on CBT interventions at our next session, particularly behavioral
activation strategies such as re-engagement with design projects, while also considering
additional therapeutic modalities that may benefit the client based on their response to initial
interventions.
Therapist Notes – CBT Intervention Example
Subjective
Session conducted via telehealth. The client reported a pervasive sense of low energy,
particularly in the morning, which has been affecting the ability to initiate tasks and start the
workday. Described a "cloud of negativity" that seems to hang over most days, with
workdays being especially challenging. By evening, the client feels spent and disengaged.
Concentration at work is a struggle, with even simple tasks feeling insurmountable. The
client also noted increased isolation, avoiding social interactions due to a lack of energy and
described life as feeling "gray." No thoughts of self-harm or suicidal ideation were reported.
Objective
Therapist introduced CBT techniques to client, including Behavioral Experimentation to
challenge morning lethargy, and Cognitive Restructuring to address negative thought
patterns. Therapist also discussed incorporating more pleasurable activities in the evening
time to improve evening mood and engagement. The therapist provided psychoeducation
around depression and emphasized potential benefits of using the techniques to combat
depressive symptoms. Therapist and client practiced together during the session and
discussed the applications of these techniques in the client's daily routines. Client was
receptive to interventions and reported that he will try to implement them consistently.
Assessment
Client presents with symptoms indicative of major depressive disorder, including persistent
low mood, anhedonia, fatigue, difficulty concentrating, and social withdrawal. These
symptoms are causing significant impairment in occupational functioning and social
relationships. Despite the absence of current suicidal ideation or self-harm risk, ongoing
assessment remains critical due to the severity of depressive symptoms. The introduction of
targeted CBT interventions is expected to incrementally improve daily functioning and mood
regulation.
Plan
Client will implement the discussed interventions, such as breaking down tasks into small
parts and more actively challenging negative thoughts in order to provide more structure in
routines. Progress with these strategies will be evaluated at the next session. This plan is
intended to help the client progress toward their treatment goals.